Insurance Question - Maybe I'll just self pay?

Hi, I have a question which I'm hoping someone can shed some light on for me. I have BCBS of Illinois . My paperwork was submitted on 4/15/04 and today I received a letter asking for 5 years of documented morbid obesity plus 1 year of supervised diet history. My year of supervised dieting will be up this fall, but the problem is this... My gallbladder has to come out ASAP. I spent the day in the ER last week - thought I had acute heartburn. Turns out I'm full of gallstones and they insist on taking it out by mid-June (I begged to post-pone surgery). Anyway, would an insurance company go for the following? Would it be a feasible idea? Insurance pays for lapariscopic gallbladder surgery. I pay the difference for the lap bypass. The self-pay price tag for lap bypass is $7500.00 here. I don't know what they charge for a gallbladder. Thanks, Amy S.

That's the same bull they are pulling on me. One year of dieting. I go back as far as 1972 on diets. When did you start your dieting? They told me 6 months and then told me they changed it on 1/1/04 to a year of dieting. I'm fighting my with Gary, the lawyer. email me if you want and we can talk. Donna

Yes, they told me 6 months of dieting, then switched it to 12 after 1/1/04. As far as I can see, they have the legal right to do that. It's not ethical in my opinion though. I'm not sure if there's much of a legal leg to stand on. I started this process last October and went to see a nutritionist right away as well as started exercising. That is what I'm counting my year from. I will say this about BCBS - when I called to ask about the status of my claim, they told me they were requesting more info. They told me (verbally) they wanted the 5 years documented MO as well as 12 months of a m.d. supervised diet, pharmaceutical history, supervised exercise program, and a plan for continuing this into the future. Now, when I received the letter, it was written much more lenient than that. It just basically says it wants 12 months of the doctor supervising my weight loss attempt. I called BCBS and they said Weigh****chers was fine as long as I had been going to the doctor and he had been monitoring me. Amy S

October will be a year for me also. They have the right to change their policy but it's not right to make the ones that have been fallowing the 6 month diet change to a year. BCBS is trying to do away with WLS so they are dragging their feet. What happens if they stall and 2005 comes and they out do WLS. Does that mean I'm SOL? I have come to far to let them win. Donna

I agree that it is not right. And it wouldn't surprise me at all if BCBS removed WLS out of all their policies as they were renewed. Question for you - have you found out what the legalities of having them quote verbally or in writing 6 months, then change their requirements. It would seem that if they communicated 6 months in some way, the patient should be "grandfathered" in. What do you think? Do you think that the heat they are getting from the press and the angry customers is making a difference to them? I hope it is. Amy

From what I have been told is that BCBS is the first insurance company that is trying to do away with WLS by the year 2005 and people getting angry is not going to change their tune. Gary, the laywer is handling the 6 month issue for me as you only have so many days to appeal it. I have had a few people write me and tell me that I should fall under the 6 months, not the year. I have nothing to lose at this point. If I win then I get my WLS sooner, other wise I keep with the dieting and seeing my PCP until October and hope they don't put me off until 2005 and tell me. Oh, sorry but we don't cover WLS. You can come out and ask this question about Grandfather rights to Gary on here and he might answer it. Just put in the title "Question for Gary" I would do it but I'm running late and must get to work. I also know that these insurance companies play games. You call Monday and then call back Tuesday and get a whole different story. I did not get jerked around by BCBS of ILL until they threw this loop hole in here on a years diet.

Don't you DARE crack open your wallet to self pay! You need to appeal PRONTO, and have your doctor write a letter stating your gallbladder needs to come out right now. Make a business case for having one surgery instead of two. Show how it will save money by doing everything now. If you are just a few months short of the year, they might not even flinch. If they do, I would fight, fight, fight! Roberta