Question:
Can an insurance company exclude long-term complications of WLS?

My HMO has a policy of excluding coverage for any complications arising from a non-covered surgical procedure. In other words, if I self-pay for WLS, they are telling me that they will not cover ANY post-op problems I might have, whether the problems occur while I'm in the hospital or five years later. If I have a bowel obstruction 18 months after the DS and need an emergency operation, my HMO is trying to tell me that I'll be on my own, because they wouldn't have approved the WLS if I'd gone through them. This is very scary to me. Does anyone have any information about whether an insurance company is within their rights to permanently exclude late-term problems like that? Should I try to switch to another HMO (my job offers a choice of two HMOs and that's it) so that my "new anatomy" can be considered a pre-existing condition? Would that get around the problem? Do any of you happen to know what the law has to say about this kind of thing? I called the Florida Department of Insurance, and they said they didn't know... it's a gray area. I also wrote to Walter Lindstrom, hoping that he might be able to offer some information or advice.    — Tally (posted on May 10, 2002)

May 10, 2002
Yeah, I heard the same thing, that if the WLS is excluded, so would any any complication that would result from the WLS. I would imagine if there's a gray area where they're not sure what was the cause, then that could be debatable. But, if it can be directly linked to WLS I also heard that it would be denied. I suppose it varies with different companies. Like most things, it depends on who you talk to when you do the claim and if they're in a good mood or not. (At least that's what one lady who works for my insurance company told me). But, if you have an option to go with another company who covers WLS, that seems like that would be the way to go! Good Luck!
   — Laurie Z.

May 10, 2002
Well, the other HMO doesn't cover WLS surgery any more frequently than my current one does. The only reason I might switch would be to take advantage of the federal law that bars insurance companies from denying coverage for "pre-existing conditions." What I'm really wondering about it is whether that law applies when the "pre-existing condition" (e.g., a permanently altered gastrointestinal tract) is the result of elective WLS. It seems ridiculous that I should need to change to a new HMO that has almost IDENTICAL coverage and policies as my old one... but health insurance is quite a ridiculous game, as we all know very well by now.
   — Tally

May 10, 2002
Another thing to consider is they may not cover your future lab work either. If they consider them directly related to your surgery, such as the malabsorption factor, they can refuse to cover them. At least that's what I understood.
   — Shelly S.

May 10, 2002
Well, that's an interesting idea. . .perhaps if you had the surgery with the one company and then switched to the other company so any complications would be covered, I don't really know if that would be covered or not. I would almost venture a guess that they would cover it (as long as they weren't the company that denied WLS). It would be interesting to find out. That always scared me about not knowing whether they'd approve and considering self pay . . .what if there were complications at the time or later and I had to pay countless dollars out of pocket. I know a woman who had to be in the hospital an extra week or so, that would be pricey and she had complications for months afterward. But if you could switch to another company, that may solve the problem. Hmm, interesting.
   — Laurie Z.

May 10, 2002
I think the laws vary on a state-by-state basis. I know here in Maine that all my follow-up lab work, etc. has been totally covered through my HMO (Cigna), even though they have a definite WLS exclusion. Also, they said they would cover an incisional hernia, since it could have happened with any abdominal surgery and is not specific to WLS. Make sense?
   — Terissa R.