Question:
Is this grounds for a discrimination suit?
I was denied surgery based on a written exclusion which I was planning to appeal knowing that I probably would not be successful.In getting my appeal together I went to the BCBSTX website to find the correct address and noticed a list of topics on keeping healthcare affordable under that was a subtopic titled "eat responsibly"and it suggests that health care can be more affordable if we control obesity and its health related costs by making responsible eating choices. I was appalled that BCBS would be so insensitive and would have the nerve to put that on their website. However I feel that this may provide a grounds for having the exclusion removed. What do you all think? Ive already written a nice little letter to the customer service department and used terms such as insensitive,discriminatory,derogatory media attention and law suit. Am I on the right track here? — Lisa F. (posted on April 28, 2003)
April 28, 2003
As a public health major, I do not feel that this is a case of
discrimination-it is the truth. It costs insurance companies more money to
cover obese persons and the illnesses that accompany being obese. Eating
right and exercise are just things that they are stating you can do in
effort to control or reduce the epidemic of obese persons in America. I
also think that because they realize the strain of obesity on insurance
pockets that they should cover the cost of WLS, I just think that you may
be upset because WLS is not covered, but you can definitely use the info on
their site to help prove your case for needing WLS. Good Luck with
everything
— TotallyTori
April 28, 2003
Thanks Victoria but I look at it as discriminatory for tis reason...why
would they feel it is ok to make that statement about obesity when there
are other illnesses that could be prevented by acting responsibly. For
example if they were to make the same statement about HIV/AIDS it is true
that by being responsible sexually the costs of treating this disease and
related ilnesses could be lowered but what would happen if they put THAT on
their website. Furthermore we know that HIV/AIDS can be contracted through
other means not just unsafe sex just as ALL obese people ARE NOT
irresponsible eaters and may have other causes for their obesity.
— Lisa F.
April 28, 2003
I'm curious.. do they state anything about irresponsible smoking or
irresponsible sex? If not.. I would say you have a case against them.
— SJP
April 28, 2003
A lawsuit for discrimination is based on discriminatory actions due to age,
race, sex, gender, national origin, etc., etc. I've never seen a lawsuit
be successful because insurance companies chose to cover various diseases
in different ways. I do not view this as discriminatory. Use your appeal
to show them how it will affect their bottom line, their own pocketbook. I
am currently appealing a written exclusion in my policy and in my appeal
letter, I have documented how much they have spent on me for the last two
years. That cost would have covered about 3 of these surgeries.
— Debbie B.
April 28, 2003
I think that if they put stop smoking and having irresponsible sex
contributes to the increase in HIV/AIDS infection, I still don;t think that
is discriminatory-again it is the truth-certain behaviors lead to certain
illnesses, and I am willing to bet that the majority of obese persons are
obese because of reasons that they can control they just don;t have the
willpower to do so which is why so many of need or want the surgery. Yes,
it is true that there are things such as thyroid probs etc, that is not why
many of us are overweight-let's get real here.
— TotallyTori
April 28, 2003
I am from Indiana and I have BCBS also. On the website for them in Indiana
they have a webpage for Gastric By Pass. I included it when I appealed.
— Autumn
April 28, 2003
Ok maybe I should change the word discriminatory to prejudiced against how
is that? ... Victoria I assume that you are also seeking to have this
surgery otherwise you probably would not be on this site,I hope that those
classes you are taking also teaches you some compassion because with your
statement you have just helped to perpetuate the MYTH that obese people are
that way because they have no will power and are greedy and lazy.I am sure
that there are THOUSANDS on this site who would beg to differ with you and
if such is the case explain to me my 16 year old who eats very moderately,
makes good choices most of the time and has been a dancer since age 3 so
she is not lazy or glutonous and yet has a BMI of 29 whish is considered
moderatly overweight, please keep in mind that me,my brother my mother my
grandmother and almost all of my aunts on my mothers side have been
overweight now tell me were ALL overweight because we're
irresponsible.Please do some research before you continue to make these
kinds of remarks.
— Lisa F.
April 28, 2003
Lisa,
I totally support your ideas about filing a discrimination suit. The idea
that obese is caused by the person is "old thinking". If someone
can sue a business for not hiring them because of their weight, then why
can't you file a suit against your insur co for not covering surgery that
would help to make you healthier?!
Is there discrimination against (slender) ppl with diabetes? With
epilepsy? With MS? Are treatments being denied to them?
I think it's very obvious in this country that discrimination against obese
ppl is the last of the accepted discriminations. It's really sickening and
it's time for ppl to make a stand. I think it would be courageous of you
to do so!!! Go for it!!!
— Lisa I.
April 28, 2003
I'm missing something here. If they believe that obesity can be controlled
by responsible eating and they have an exclusion for WLS, that seems to
follow logically to me. While they recognize that obesity leads to higher
health costs, their solution to obesity is not in line with yours. That
doesn't make for a discrimination suit. I'm not saying that they're right
but I don't think this is actionable.
— susanje
April 28, 2003
It is a known fact that stress causes many illnesses. I truly believe that
insurance executives who don't controll their stress ought to be refused
heart surgey. It is simple, don't feel stressed out and your heart will go
on forever. It is all so logical, NOT.
— faybay
April 28, 2003
I think we're all looking at this from different view points. To me it
sounds like they are trying to *prevent* obesity and consequently the
costs. I do think that obesity could be avoided in SOME situations.
Consider adults who don't gain until in later adulthood due to lower
metabolism, less activity, and too much caloric intake. (usually not going
to become morbidly obese anyhow) Or children who could be helped to slow or
perhaps stop the obese trend if they ate better & exercised. Even WLS
forces us to eat more responsibly, at least how much we're eating and the
post op diets given incorporate "healthy eating" so to SOME
extent we buy into that when we decide to put ourselves through the
surgery. Although I DO think that insurance companies discriminate against
the obese, I don't think they intended this particular comment to offend
anyone. I bet if you went in and looked there would be other subjects
besides healthy eating like exercise, taking your vitamins, seeing your
doctor regularly. Pretty much the standard advise we've all heard our
entire lives. Having said all that, I totally relate to your feelings of
frustration and irritation with insurance companies. Many of us are self
pays because of their "policy" (aka discriminatory methods) of
not allowing obese people access to their policies that cover this
procedure. I wish you the best of luck in your appeals process.
— Shelly S.
April 28, 2003
You are looking at MO through eyes that don't quite get it. So many thin
kids eat nothing but junk food. The difference is more than just
metabolism. By the way my husband and I come from thin families. I must
tell you that growing up I was the healthier eater and more active than the
others.
They are isolating more and more genes every day. I saw a special on the
learning channel. For some of us the chemical or whatever, that transmits
the message from the stomach to the brain that it is full, does not work as
it should. The brain never thinks it is full. So just like the brain
tells us to breathe it tells us we are hungy. Then there are addictions.
Those who are addicted to sugar, cannot ever have it again. Just like the
alcoholic. But just like the alcoholic, after they have been off the stuff
for a while, we convince ourselves we can handle a small portion and then
wham, a full blown binge. It is so much more complicated than just teaching
our kids healthy eating habits. The tool we get (and the tool does not
always work), help us get to the point where we are capable of using the
the good eating and exercise guidelines.
— faybay
April 28, 2003
Sorry, I was responding to Shelly sweets post.
— faybay
April 28, 2003
I'm sorry, but I don't see that statement as discriminatory. Say they made
a similar statement about alcohol consumption? No one can arge that
alcohol plays a major part in ER visits, and costs insurance companies big
bucks. Many will argue alcoholism is a disease, and the person cannot help
it, but the person can get treatment. Our idea of treatment for MO is WLS,
but obviously, it's not BCBS's. But the basic premise is the same -- if
there is less obesity, insurance costs will go down. They may be
short-sided when it comes to how to obtain less obesity, but not
discriminatory in my opinion. Maybe you can point out their faulty logic
with lots of good research about the long-term benefits of WLS.
— [Deactivated Member]
April 28, 2003
As a lawyer, I can assure you that it isn't discriminatory. (NOTE: I am
NOT providing you with legal advice). Indeed, I don't even think
(personally) that it is insensitive. As others have stated, it is the
TRUTH. And....I'm pretty sure that one of the ways insurance companies
(and other public health organizations) try to stop the spread of HIV/AIDS
is by educating the public on ways to practice safer sex, etc. Now, I
agree that for a lot of us, "eating responsibly" isn't going to
"fix" our morbid obesity. But there are a lot of people out
there who, believe it or not, don't understand the connection between the
krispy kreme or the McDonald's and the ten pounds they can't seem to lose.
This website wasn't directed at you...its BCBS' way of educating the
public. I feel for you, I do -- and I hopehopehope you can get them to
overturn their decision. But this isn't the way to do it.
— Tamara K.
April 28, 2003
Ok, I have to agree with everyone here to a point. However, Victoria (who
is being flamed for her opinion and shouldnt be) does have a point. Yes
there are 'other' factors that cause some people to weigh more than others.
Or make it more difficult than others to maintain a socially or medically
acceptable weight. That being said--it does all boil down to the fact that
if you are overweight you eat more / excersize less than you should for
your body. Someone posted about their daughter that didnt eat a whole lot,
was active and still was considered 'overweight'. OK, before surgery I
could honestly say that I really didnt eat that much. I was not active at
all, still am not...but really didnt eat that much compared to my other
obese friends. My family and my friends really couldnt figure out why I
weighed what I did. After you have this surgery, the first several months
are rather difficult in the fact that you begin to come to terms with WHY
you are fat and WHY you eat. For the first few weeks I would find myself
wondering around the kitchen digging through cabinets and through the
fridge looking...looking for something to eat...unfortunatly this surgery
makes you really LOOK at what you are eating and you actually have to THINK
about what you are doing. I began to realize that I ate out of stress and
emotional upset. I also began to realize that while I really didn't eat
that much, I would grab a handful of this and a handful of that whenever
stress came my way. Therefore---eating far more than I should. Unitl you
have this surgery, you will not know what I am talking about. Of all the
responses to this question...one of you are post op. I do not believe
insurance companies are discriminating against obese people by having the
exclusion in their policies. I think it is insane that WLS is being
compared to heart surgery in this forum. Yes this surgery can and will
prevent and or eliminate other health risks associated with obesity...but
come on people...and be honest with yourselves if you cant be honest with
me...how many of you here actually began researching this because of health
issues? Yes there are some that have...but having been reading this site
for the past 4 years...I know the majority do not. They convince
themselves of that over time. I know I did. But I can be very honest that
I initially researched this procedure because when you are overweight you
will grasp at anything to be thin. And immediatly become the victim, and
if it isnt going your way...then law suits are thretened, letters are
written, and ins companies begin being bashed. Back to the discrimination
topic here. I have worked for a major health insurance provider for the
last 5 years....MOST insurance companies provide coverage for this
procedure. The exclusion is set by your employer when they purchase the
plan that they provide to you. By suing the insurance proveder for
discrimination you will lose. Suing the employer you may have a shot.
However, they opted, most likely, to put in that exclusion to make the
coverage less expensive for them and for you. This surgery is not cheap,
and alot of people that are overweight want it. And unfortunatly alot of
them barely qualify for this surgery....such as myself when I had it. In
my opinion, if I was the all controlling WLS aprover....I would not have
approved me for WLS with only having a bmi of 43. IMO, this surgery is for
people that have BMI's of 50 or greater, or if lower...they better have
some major helth risks. Now before you flame me for my opinions that do
not agree with your own,....have this surgery first. Have it and wait a
year then respond. Your view will change dramatically. Sorry for
offending, Im sure I have. But it really frustrates me when people dont
look at things from all the angles or make predjuce statements about
'insurance company A' just because THEIR policy has an exclusion. BX pays
for this surgery....unfortunatly your company does not.
— RebeccaP
April 28, 2003
I am expecting to get bashed for this one. I am assuming that I am the only
one here who did not exercise much and ate way too much pre op. Anyone who
has dieted and lost weight was eating too much before that. I am not saying
that there are not other contributing factors but I played a big part in my
own obesity. If I were fat and not eating before then how would this
surgery work for me? I come from a family of obese people and the cards
were probably stacked against me from the start but it was not all genes,
we like to eat. As a smoker my insurance premiums ARE higher and there are
probably more AIDS patient on welfare and state insurances than on my
insurance plan so I do not see this as prejudice any more than anything
else. After surgery are we offended by having to eat less and exercise? If
I could have done that before and avoided surgery I would have. It is a
catch 22 for sure. That said I cannot believe that high insurance costs are
blamed on obesity. That is rediculous and I feel it does perpetuate the
prejudices. And as long as there is something people think we can do about
our obesity I don't see the prejudice going away. People who have never
been overweight can be pretty smug about it. I will be curious to see what
you do with this and what happens though. I am sorry if I have offended
anyone it is just my opinion and we know what those are like, everyone has
one! hee hee! Good Luck.
— Carol S.
April 28, 2003
OK, let's all concede this: We are (or were) obese because - barring some
other medical problem - we eat (or ate) too much. And it IS true that
eating right and exercising is healthier than how we eat. That being said,
it is well and widely recognized that morbid obesity is NOT a matter of
willpower - it is a matter of physiology. Until the medical community can
come up with a suitable pharmacological solution, WLS is usually our best
hope of dealing with what causes us to be obese: overeating. Now, whether
or not an insurance provider covers bariatric surgery is more a matter of
whether the employer is paying for an insurance plan that includes WLS;
nearly every insurance provider covers WLS, just not every employer buys
the policies for their employs that include that service (the more services
covered, the more expensive the policy). If you feel that you were denied
for WLS for a reason that is in direct violation of the stipulations set
forth for the policy that was purchased by YOUR employer, then you have a
valid appeal. But it's unlikely that you would be successful in a lawsuit
against an insurance company if they are simply providing the services that
the employer is paying for - it would probably be more beneficial to take
it up with the employer, and try to persuade them to obtain higher levels
of insurance for their employees.
— johanniter
April 28, 2003
My opinion...there's no basis for a law suit here. How can an insurance
company telling you that if you eat right and make responsible eating
choices it will help defray healthcare costs be prejudiced when it's true?
Also, as to the remarks about AIDS, alcoholism, etc., obesity claims more
lives than any other disease and has become an epidemic...I heard a
statistic that obesity increases your risk of breast cancer by 500%.
I don't think that it's fair when you ask for others opinions then flame
them for giving it. Obviously Lisa you are very angry, but remember WHO
you are angry with. I cannot blame you for that and ALL of us here have
had our issues with insurance companies. Your place of business is the one
responsible for changing exclusions in your policy. The health plans
offered by your employer to you, are a contract between your employer and
BCBS. The exclusion is something your employer agreed to, then when you
signed on for employment and insurance..YOU agreed to these exclusions. I
would start with them and not go screaming "law suit"...honestly,
you don't have a leg to stand on. I'm sure BCBS's lawyers have ok'd this
display on their website.
Just FYI..I used the Lindstroms for my appeals process and they informed me
that they were no longer accepting clients with BCBS because of these
exclusions and there being no way around them. You might want to give them
a call though, they will give you advice on whether or not they can help
you and might be able to lead you in the right direction. Good luck and
Blessings =)
— Kim D.
April 29, 2003
While my personal opinion is that this does not represent discrimination,
merely advice on health prevention issues, I do think you should focus on
your appeal, making it the best that you can. Have you contacted your state
insurance regulator. Here's a link to a government site that offers
complete name, address, phone # etc. for each state's insurance
commissioner. http://www.pueblo.gsa.gov/crh/insurance.htm Also, I
recommend you read the current (May 2003) issue of Reader's Digest. It has
an article about how to get your health insurer to pay up. Basically it's a
run down on statistics of appeals, where to go when your appeals have been
exhausted, etc. Very encouraging article actual. Good Luck to you - Anna
LAP RNY 7/3/02 -123lbs.
— Anna L.
April 29, 2003
I also expect to get bashed here but this reminds me of the man that filed
a lawsuit against McDonalds because he was obese. ( It was dismissed)
— Delores S.
April 29, 2003
No, Lisa, I think that you are way off base. Insurance companies have the
right to exclude weight loss surgery, just as you have the right to find
another insurance company. I don't feel that the advice that BC/BS of
Texas is insensitive, discriminatory or derogatory - it is just good
advice. It is advice that we should have paid attention to years ago and
we didn't - otherwise, we wouldn't have had (or are going to have)
weight-loss surgery.
<p>
I know that you feel that it isn't fair that your insurance company has a
written exclusion for WLS, but it was simply a business decision for them.
I would simply go ahead with the appeal on my own or get Walter Lindstrom
at http://www.obesitylaw.com involved. Or...find another insurance
company...JR
— John Rushton
April 29, 2003
I have to agree with the others, that this is not discriminatory. However,
I do believe you can USE THEIR OWN WORDS to help in your appeal. As
another poster pointed out, you have to let them know how not paying for
this surgery can affect the insurance company's bottom line. Had you had
this "valuable information" about making healthy eating choices
before, perhaps you would not be obese now, but the water is under the
bridge, so to speak, and you are now obese (morbidly so) and costs can only
be controlled in your case by allowing the surgery to reverse this
condition. If you have co-morbids (or the potential for such) do point out
the costs involved in treating those (heart disease and diabetes,
arthritis, etc.)as opposed to the cost of surgery. Personally, I think the
customer service department will get a laugh out of your letter. There is
nothing they can do about what is on the website, nor can they make changes
to the policy. They are not going to be affected by your threat of a law
suit. (Think they don't have lawyers out the wazoo that work for them?)
— koogy
April 29, 2003
Thanks to all of you who responded to this question and I ma sorry if any
of you felt you were "bashed" for your answers.Obviously I cant
sue BCBS if I had that kind of money I would pay for my own surgery!The
point is to show them and you that this type of thinking that ALL obesity
is caused by irresponsible eating and lack of exercise is ridiculous.If we
continue to let the insurance companies think this way then next year they
may decide to exclude treatment for other disease because if we had acted
RESPONSIBLY we would not have contracted the disease.What if next year they
decide that because for years research has said that over exposure to sun
causes skin cancer so by continuing to do so you contributed to your own
sun related cancer and therefore treatment will be excluded will you be so
willing to accept this decision then? In the case of the people who sued
McDonalds yes it was a little odd NO they did not win but did it effect a
change? YES Mc donalds is now experimenting with a new lower fat
menu!Although I am sure that my threat of a lawsuit does not scare BCBS but
I am sure that they would not appreciate any negative media attention a
lawsuit might bring and I hope that their customer service department would
indeed take customer complaints seriously and maybe if more of us
complained rather than just accepted and agreed with many more of us would
be having surgery instead of writing appeals.Thanks for all of the advice
and I did want to add that this wasnt the total focus of my appeal it also
focused on the cost effectiveness and how it effects them(thats a whole
other section of their website lol!)Love you all!
— Lisa F.
April 29, 2003
I never meant to imply that simply healthy eating & exercise was going
to fix everyones problems. If I came across as sounding like I was going
to just put every kid on a healthy diet and nobody would ever get
"fat" then I apologize. And Faye, I DO get it. I have a 10 year
old that weighs over 180 now. And she eats healthier than her peers! The
only way she can control her tendency to gain large amounts of weight is
through diet and exercise. We've been to dietary counceling and both have
membership at a gym. She's no everyday kid. She unfortunately inherited
my genes which do make her prone to gaining weight. She also inherited my
thyroid problem and physically I can see her carrying her weight in the
same areas as me. She has a raw deal but diet and exercise help CONTROL
and slow the weightloss. Its the only current option for children who need
some help before they balloon to become morbidly obese or even super
morbidly obese. Obviously WLS isn't an answer for these little ones so we
have to do whatever we can to help them and basically that IS diet &
exercise.
— Shelly S.
April 29, 2003
My last post didn't make it here. I must have expressed my point in too
angry a manner. If you smoke and get lung cancer, your surgery is covered.
If you chose to live a stressful life and have heart trouble, it is
covered. If you chose to drink excessively, liver surgery is covered. If
you chose to eat spicy foods, ulcer surgery is covered. If you chose to
bang your head against a brick wall, brain surgery is covered. If you
drink and walk and trip, surgery is covered. Assuming all of you are right
that these are free choices (not my belief), how is it not discriminatory
to not cover the choice of morbid obesity.
— faybay
April 29, 2003
Fay, I have to say, as someone that had to self pay for surgery 1 year ago,
and who is STILL paying for it ... I agree with you. I can understand and
'angry' post. I understand very well every month when the bill for my
medical loan comes in! =)
— KelBurt
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