Question:
I have an iron clad exclusion, and posted earlier, what do you think of this?

Hey, all! I have this exclusion, and intend to fight it, but what do you think of this? If I can come up with the surgeon's fees, will they schedule the surgery and have the hospital bill me? I found out from a collection agency (that's why I can't finance, I have bad credit due to a bankruptcy) that any medical bills sent to collections HAVE to accept any kind of payments you send in because it's medical. So I am thinking, while I am fighting with my insurance, maybe I could come up with enough to pay my surgeon and let the hospital bill me and if I still haven't won with the insurance, I can make payments on the hospital portion, which is the larger bill. Or will the hospital demand coverage or pre-payment on this kind of surgery? People, this is how desperate I am. My blood pressure continues to rise, I have been on Atkins, low fat, etc. but continue to gain. I am 43, and I know some of you know that you can have the willpower and still not lose. It seems to be hormonal and age, because 3 years ago I lost 70 lbs and cannot do it now. I feel like a time bomb and want to get this done NOW. Anyone have input? I love you all and feel the pain of everyone trying to get this life or death surgery and insurance won't cover it. If I become a drug addict, though, I can go to rehab for months and get that covered. I can smoke till I get lung cancer and they will pay for hospital care and any surgery I need to heal from that, but not this. What a discrimination. Thanks for any advice! darci    — darci T. (posted on June 21, 2003)

June 21, 2003
During my research into WLS, I remember reading some advice on this subject. If you are covered for health insurance by your full-time employer, then that employer signs a contract containing terms (exclusions) of covered procedures. Therefore, you may need to take legal action against your employer, I believe based on discrimination, to have `them remove tis exclusion from their contract with the health insurance company. If the "iron-clad" exclusionis in your policy, then clearly your employer controls that exclusion. However, you should keep in mind that your employer will likely face higher premiums if the have exclusions removed from their contract. I would suggest that you contact an attorney experienced in employment law or obesity issues. There is a web site, www.obesitylaw.com, that may have some answers. The hospital will likely require a substantial deposit to cover an elective procedure for an effectively uninsured person. If the health insurance company won't provide authorization, then the hospital and all related costs would be denied as a claim. Most state's laws only require hospitals to afford service for emergency situations, which elective WLS would not qualify. Good Luck.
   — David F.

June 21, 2003
Darci, since this surgery is considered elective, the hospital will check for coverage first before they book a surgery. Your idea probably won't work, unfortunately. I understand your desperation, but that's the way things work with hospitals these days. It would be a different story if someone came in as an emergency, and there was no time to haggle about insurance. The only thing they could do is accept a payment arrangement (hopefully BEFORE the bill goes to collection) in such a case. Sorry there's not a better answer.
   — [Deactivated Member]

June 21, 2003
It is definitly up to your employer to remove this exclusion. And threatening legal action against your employer could end up getying you fired.Remember that your employer is not required to provide you with ANY medical coverage thats why its called a BENEFIT so I dont think getting a lawyer would even do any good.Sorry the news isnt better but I had to face the cold hard facts mydelf a few months ago.Luckily I decided to relocate and the insurance through my new employer didnt have an exclusion. Good Luck to you
   — Lisa F.

June 21, 2003
Self-pay patients at the hospital where I had surgery are required to be paid-in-full with the hospital before surgery can be performed, maybe even scheduled. Have you tried simply going to your benefits coordinator and finding out if this could be checked into? Also, have you considered buying a private insurance policy that does cover WLS? Just what came to mind. Best of luck! :)
   — ladyphy

June 21, 2003
Definitely work with your employer any way you can to get them to give you a rider to cover this surgery. In my experience if you're in the position to qualify for this surgery then you aren't likely to find an individual policy that covers WLS who will take you. And if you have this surgery as a self pay and have complications insurance will NOT cover it. I'm not saying if things don't work out that you shouldn't consider self paying just urging you to try to make what you have work. As for self paying, it isn't the surgeons fees I found to be the barrier but the hospital. I found a surgeon who'd take payments but the hospital required $10,000 down and the rest to be paid off within 2 years. And if you're to the point of having to come up with $10K cash you might want to consider Mexico. For a few thousand less than the down payment to the hospital in the US you can have the entire surgery paid for in Mexico. Check out Latrisha Nickels profile with her Dr. in Ensada Mexico.
   — Shelly S.

June 21, 2003
Medical providers do not HAVE to take $5 a month like some people try to tell you - they certainly have nurses to pay, x-ray machines to buy, etc., and are not legally obligated to take whatever payment arrangements the patient thinks are fair. I'm not saying hospital charges are fair, but because people don't pay their bills is part of the reason prices are too high. The only way you are ever going to get decent credit is to not buy or use products or services you can't afford. If you save up ahead of time and offer the hospital cash you can get a discount - if you have the surgery knowing ahead of time it won't be covered then pay after the fact, they will certainly add interest. If your hospital bill is thousands of dollars, which it certainly will be, they will not be willing to take the low regular payments that most of us can afford. I personally feel that having surgery knowing your insurance won't pay, and that you plan to make payments, is fraud. The hospital bill will probably be minimum $20,000 - more like $30,000. That's like $400-$500 a month payments, not counting the anesthesiologist, radiologist, etc. I know you feel desperate to have this done yesterday, but I think you need to look into other options. Do you have a second car you could sell and take the bus? I know it sounds like a lot to ask, but the money has to come from somewhere. And of course, I'm sure the other posters are right - they will never let you have this surgery at the hospital without a preauthorization or cash on the barrel head. It may take a few years to get your credit back into shape, or be on an insurance that covers the procedure, or maybe even laws to change to this can't be denied all the time, but sometimes you have to take the long road to get where you're going.
   — bethybb