Question:
Has anyone else had the following problem regarding insur. coverage?

I called the make sure that my insurance would cover such a surgery. The lady told me yes if it was medically necessary and at least 100 lbs. overweight. Well a little time went by and I wanted to find out from the insurance company what surgeons were in my plan. They wanted to know what it was for, and they told me that kind of surgery was not covered by my plan. Called a week or two later and asked the same ? and they said it wasn't covered. I asked what page this exclusion was on in my contract (because I had it right in front of me) they didn't want to tell me. But I griped enuf she put me on hold forever and came back with a page number. After I hung up I looked that up, no where on that page does it mention anything like what she had read to me (or for that matter any exclusions). I had previously read the whole contract and didn't find any exclusion about obesity surgery. HELP!! I can see that this is going to be a real pain in the butt with this crappy insurance (BLUE CROSS/BLUE SHIELD HMO of K.C.)    — Erica C. (posted on May 31, 2000)

May 31, 2000
I was denied surgery from MSC, Premera Blue Cross I had the surgery anyway. I sent my 1st appeal letter yesterday and should be hearing a reply from them within the next month. My exclusion read "Medical or surgical treatment for obesity, whether or not the obesity is related to, aggravated by, or is the cause of other conditions." My appeal is on the grounds of this being a vague exclusion with not distinction made between obesity, and morbid obesity with co-morbidities. I sent letters stating medical necessity also. Don't let them intimidate you, this may be the single most important medical decision you may ever have to make for yourself. I am 10 and 1/2 weeks post-op and have already lost 48 lbs. and feel like a new person. 68lbs to go. I feel "Great"! Good Luck Hugs
   — Jeanie W.

May 31, 2000
I was denied by Priority Health in Michigan. I appealed over and over again and after six months of that I got in contact with Walter Lindstrom in San Diego, CA. He is an attorney that is an advocate for this surgery. He is extremely helpful, knowledgeable and VERY affordable. He also has had this surgery. Well to make a very long year's story short we had to appeal all the way to the State of MI HMO Task Force. this was my last result before deciding whether or not I would sue them. Well, Praise the Lord, we WON that appeal. I couldn't believe it because six months prior, the Task Force ruled in Priority Health's favor in a similar matter. The difference was that the president on the Task Force was a physican who had a patient who had this surgery and he was convinced on how much a difference it made in her life. He said "If I had another patient who wanted this surgery. I would move mountains for them to get it." It gave me goose bumps and Priority Health's lawyer and physician representative left with their tails hanging. What a victory. I only tell you this so you won't give up. There are options and places to investigate. If you are interested in contacting Walter Lindstrom his website is www.obesitylaw.com Sincerely, Cindy
   — Cindy M.

May 31, 2000
I have BC/BS of GA-federal/PPO- I was approved for VBG in two short weeks. Look in your policy under exculsion and see what it says about weight loss. That is where it is addressed in my policy. It excludes weight loss medicines and program yet it has the surgeries as an exception to this rule. Call back and ask again. I do know that if you Blue Cross policy is one that you bought for like your own business then it probably excludes all weightloss medicines and procedures. The lady you talked to may not be the right person to talk to, ask for the supervisor. I have had a wonderful experience with BCBS so far.
   — Teresa M.

February 24, 2001
Erica, I too was told by BCBS Blue Advantge (HMO) prior to my vist with my WLS doctor that the procedure would be 100% paif for if it wass medically necassary and then when the doctor submitted the paperwork for approval it was declined stating that BCBS HMO does not cover any obesity management treatment or surgeries.
   — Katherine S.