Question:
I am so confused about my insurance right now, Matthew Thornton Blue,

blue cross blue shield... I have read everything on this site pertaining to this, some people were covered with no problem, some people have had to do appeal after appeal, and some people are suing the insurance company, what decides these types of outcomes??? alot of these seem to be the same type on insurance but they all state different type of exclusions, and people have been approved with the written exclusion?? I am really confused and dont even know if it will be worth if for me there is a strict exclusion for WLS for obese and morbidly obese for any reason at all no matter what, so will i get approved or am i wasting my time, it is so confusing, i am also insurance illiterate so that does now help!!!    — Amy B. (posted on April 3, 2000)

April 3, 2000
Amy, this is a very confusing subject. Insurance coverage and laws vary from policy to policy and state to state (for instance, my Blue Cross California Care group coverage, which is provided by my employer, covers WLS -- but the Blue Cross California Care individual policy doesn't). A lot depends on what state you live in and its laws governing insurance and appeals. In California, we have a third-party appeal mechanism, so insurance companies DON'T have the final say about what's covered and what isn't (the Department of Corporations can override a denial, even if it's based on excluded services). You should research the insurance laws in your state, and find out what the "trend" is in overturning denials. There are probably some good consumer advocacy groups in the nearest metropolitan area who can help you with this. Also, there's more than one way to skin a cat - you may be able to get the surgery covered if your physician will go to bat for you and document that the surgery is the best way to treat a covered condition such as diabetes or hypertension (as opposed to a non-covered condition like obesity). I can tell you this - you're in for a fight! But where there's a will, there's a way. If I can be of assistance, please don't hesitate to contact me.
   — Kim H.

April 3, 2000
When you signed up the insurance company gave you a policy information packet. One was a book of participating doctors, the other was a book that tells you what your group coverage is. If you do not have those talk to your Human Res. dept. They will have copies to give you. Look under Obesity and there you will find inclusion and exclusion info like if surgery is covered only if medically necessary etc. Hope this helps.
   — Courtrina Amur W.

April 3, 2000
Insurance coverage is confusing. Insurance policies are regulated by state governments and each state has its own set of laws and regulations. While there is much uniformity, there are also lots of differences. To understand what your benefits are, you have to start with the language of the insurance policy. Go the explanation of benefits booklet that you received when you signed up or at renewal. First, read through the exclusions and see if there is a specific exclusion for obesity treatment or weight loss surgery. If there is an exclusion, see if there also is an exception for such treatment if it is medically necessary. If there is no exclusion, or if the exclusion is somehow limited, then call the insurance company and ask to speak to a customer service rep and ask that person what the criteria for approval is. Also, talk to your doctor's office staff and ask them about insurance experience, particularly with your carrier. If you are getting a run around, each state has an insurance commissioner. That is a person, sometimes elected, usually appointed by the governor, who is responsible for regulating the insurance industry in that state. Each insurance commissioner has a staff that handles consumer complaints and questions. This stuff only seems complicated because you are not used to dealing with it, but you can understand it and deal with it, with a little perserverence. Good luck to you.
   — Kathleen B.

April 3, 2000
I am confused too ! I have an Exclusion in my policy but there seemes to be a slight little maybe for me. But it is a long shot or so I have been told. My Policy states " they do not cover WLS if the surgery is just done to control weight. My surgons office staff refuses to even send in the paperwork in my behalf. Because of the Exclusion. It is my guess that getting people approved is a very difficult process, one they choose not to bother with. In any event I figure I will take the advice posted here and change INS but trying to make sure that WLS is covered before making any change. Most Companies or Employers choose what is covered, because you can have the same Insurance Plan and have different coverages. Hope this helps a little, you are not alone !
   — Tamaria W.

April 3, 2000
I am confused too ! I have an Exclusion in my policy but there seemes to be a slight little maybe for me. But it is a long shot or so I have been told. My Policy states " they do not cover WLS if the surgery is just done to control weight. My surgons office staff refuses to even send in the paperwork in my behalf. Because of the Exclusion. It is my guess that getting people approved is a very difficult process, one they choose not to bother with. In any event I figure I will take the advice posted here and change INS but trying to make sure that WLS is covered before making any change. Most Companies or Employers choose what is covered, because you can have the same Insurance Plan as someone else that works for a different company and have different coverages. Hope this helps a little, you are not alone !
   — Tamaria W.