Question:
Has anyone experienced a problem with insurance caps. Meical mutual has a cap of 10k

I contacted them today, they informed me the cap was placed because bypass has become a popular surgery. They feel there are other methods of losing weight that won't cost them 35k. You can have a blockage in a valve in your heart from poor eating habits. They will cover that life saving surgery. The gastric surgery is not considered life threatening. I need advice on where to go to fight for my life and that of others that need it.    — Nancy B. (posted on September 30, 2003)

September 30, 2003
I am sorry to say, but I don't think you will be able to get around this. You may talk to your company you work for as they decide what to cover and what not. I have Medical mutual also however, they do not have a cap on mine. Out of pocket maximum does not apply to this procrdure.
   — daddy43302

September 30, 2003
Call Medical Mutual back and ask them if the $10,000 cap is based on the actual charged amount OR if it's based on the actual paid OR contracted amount. This could make a HUGE difference. If you are on a PPO plan, if the hospital CHARGES $30,000 but the CONTRACTED amount is $3000 and the insurance PAYS $2500, then either $3000 or $2500 would go towards the cap. If it is this way, then you should have no problems staying under the cap. Companies like Medical Mutual get HUGE discounts from hospitals and that's they largest bill from WLS. If they do handle it based on the contracted or paid amount, your next step would be to contact the hospital where your having the surgery done. I would ONLY have it done at a PPO hospital in the Medical Mutual network so that costs remain low. Talk to someone in the billing department at the hospital and explain your situation and tell them that you need to find out what is the contracted amount for an in hospital stay with Medical Mutual. They should be able to tell you this. If not, ask to speak to a supervisor.
   — Patty H.