Group Health Insurance Question

Has anyone ever been successful in having group health cover the wls. I have the group health options. This coverage is new to me but I asked the representative and she said group health does not cover wls period!! Thanks for any input in this. Trish

Hi Tricia, It all depends on your plan. Different companies get different plans for their employees. I have Group Health and will have my surgery on October 4th. I was approved last December. There have been a lot of plans that have been ending their coverage of WLS at the end of the service year. For some people that's September, for others it's October or the end of the year, etc. Because of this the 2 surgeons have been trying to squeeze in as many as possible before their coverage runs out. I work at a Federal office and mine isn't ending the coverage. So, check your benefits packet you got from work and read it for yourself, or call whoever it is at work that handles health benefits. But if you called Group Health, they are incorrect if they told you WLS isn't covered, period. Maybe just your plan doesn't cover it because the employer didn't want to pay the cost. Happy Clam

Clam, Congratulations on your surgery date of Oct. 4. WOOWOOWOO!! If you posted it earlier, I forgot. Which Dr. is doing your surgery? How are you doing on the pre-surgery diet? Shakes, shakes, and more shakes? Mari

Hi Mari, Dr. Au is doing my surgery. I'm doing a combo of shakes with fruit added to them and lean cuisines. The weight loss is slow so far, so I'm upping my exercise. How are you doing post-op? Happy Clam

I have GHC and all WLS-related procedures are excluded from my plan (as well as any direct complications arising from WLS). However, hope lies in the fact that GHC has a clause in contracts that states: Individual Case Management (CA-90001, pg. 29) When medically necessary and cost-effective, Group Health may provide alternative benefits to an enrollee on a case-by-case basis. In order for Group Health to provide alternative services, a written agreement that specifies services, supplies, benefits and limitations must be signed by the enrollee, the PCP and Group Health. Group Health reserves the right to terminate these extended benefits when the services are no longer medically necessary, cost-effective, feasible, or at any time by sending written notice to the enrollee. I am hiring a lawyer to pursue this avenue further for my second appeal since, although I based my initial appeal on this argument and had a letter of support from my PCP, I still got a generic denial from GHC. I think it'll take bigger guns to budge them from their position. Good luck. Tina

Hmm, I heard that Group Health had recently set up whole bariatric program for RNY. I think Dr. Lauter who is a great RNY surgeon helped them set it up. If the RNY is what you are looking for I think you should try to get more information. That said, I had Group Health until 2002 and had a mixed experience there. They are great for some things, but I found them to be penny pinching in others. The reason I left them was that they refused to let me have general anesthesia when I had a misscarriage and required a D&C. Instead I was given a cervical block, which was in itself extremely painful, requiring several shots in the cervex. Despite the cervical block the D&C was probably the most painful thing I have ever had to endure both physically and emotionally. Afterward I called around and was told by every other OB/Gyn office I talked to that it is normal proceedure to offer general anethesia in these cir****tances. I believe the only reason Group Health refused was because it would have been more expensive. I suggest finding out as much as you can about their bariatric program before signing up. I did notice that the things they set up programs for seem to work really well so it might be just what you are looking for. Best of luck to you, Laura

Wow Laura, I can't believe that happened! I work for Group Health so of course, I'm a patient. I had a miscarriage a few years ago that required a D/C but there was no question, I had general. I've never heard of a doc cutting corners for cost like what happened to you! My son was just circ'd at one year old (adopted) and they did general too. I do know that whether or not GHC covers WLS is up to the plan your employer purchases from GHC. My surgery is covered (for now - knock on wood) but I have heard a rumor that more and more employers are opting to NOT carry the coverage for their employees. Whoever at Customer Service said that WLS isn't covered PERIOD is a moron. Maybe your plan doesn't cover it PERIOD but GHC certainly offers it as an addition to the plan your employer purchases. I am sorry some of you have gone thru such a mess! GHC is trying hard to improve their reputation and I personally LOVE having GHC for the past 6 years. If anyone has any GHC questions, please don't hesitate to contact me by email [email protected] I'll get ya some answers! Take care, Sandy