GOOD Insurance stories

[wavydaby]

All too often, I see horror stories of denials and long tedious appeals. It almost made me want to say, no I dont want to get my hopes up.
BUT I did!!!
I wanted to say that my employer does have the rider for LB and I was approved in less than 3 days for surgery.

Things to know
I had all my paperwork in to the Dr. (blood work, weight loss/gain history, psych evaluation, etc) The insurance will give you problems if they are missing paper work.

Do not be afraid to call your HR department and ask them if they cover LB. At first I didnt want them to know who was calling when I asked them if ins will cover it. I did get my answers and they didnt get my name.
Now I dont care who knows.

If the insurance company denies you, get a case worker assigned to your claim and bug them for a clear and consise answer as to why you were denied. Sometimes, the Dr forgets to add that xyz paper in to the pile.
Find out the appeals process, and work them to death. If you give up, God knows they will, and sometimes, in reading others experinces, I think the ins comp was HOPING that the person would give up.

This is your life, never give up, never surrender!!!!

[Jachut]

Heheh, well you go to doctor, get diagnosed with whatever, go see specialist, and then go to hospital and get fixed. Insurance covers it regardless.

Over here, we bitch about the gaps but its paradise compared to what you guys go through. Here, you can go through the public system and have a baby, and it costs you nothing. If you go private, your insurance covers the hospital stay and some policies cover the obstetrician's gap (the difference between what the scheduled fee for that service is and what the surgeon/specialist actually charges) but you will be out of pocket a few thousand because of that gap. Still I'd rather have a week in hospital, a private room and good food and wine after I've pushed out a baby myself, than go in and get sent home a day or two later before your milk's even come in. Regardless of whether you have private health insurance or not, Medicare will cover 85% of the scheduled fee for most services.

We really have an excellent health care system in this country. There's no quibbling about lap bands either, if the surgeon says he'll do it then its covered, no questions.

[PhotoNut]

Do they exist?? LOL

I don't have any insurance. Flying by the seat of my ever-shrinking pants!

[Diva]

I have BCBS Blue Choice New England. No problems at all. I called first and got their policy in writing. NEMC assured me that if I met the criteria it would take about 48 hours to approve.
I met the criteria. It was the usual, higher BMI than 40, co-morbitities, apnea, diabetes, high blood pressure. I had none of those except sleep apnea and a "holy crap-that is freakin' high!" BMI of 51. I didn't even have to prove the apnea due to the high BMI.
I got approved in a day.

[Plainsneech]

I have Keystone which is an HMO of BCBS. I was approved in about two weeks. Needless to say I was elated because the boards had me geared up for a fight with satan himself to get approved.

[Mrs Sabre]

I didn't meet the "standard" definition of morbid obesity. My 5-year average BMI was in that gray area of 35-40 where the insurance companies want you to have high blood pressure, diabetes, or heart disease. I don't have any of these things. It took them over 4 weeks to deny approval. I had an appeals letter faxed to their appeals department before I got the written copy of my denial. I don't have the standard co-morbidities, but I was able to list 7 others that are weight related. They overturned the denial in less than two weeks! :) It pays to fight. Just because you don't appear to meet the “standard” criteria doesn't mean you don't need a Lap-Band.

[mrs_christy]

My insurance was surprisingly cooperative! I have United Health Care of AZ (HMO) and only waited 8 days to get my approval after the doc had sent everything required. I called EVERY day to be sure the paperwork was not only received, but also in review, and once approved that the letter was in the works. I heard that UHC was "easy" to get approved for this surgery, but had no idea they were THAT easy. I only had one problem I ran into, but it wasn't my insurance, it was me turning in the correct paperwork according to their guidelines. Be sure to ask for a LIST of the documents you need before you submit!

[HeatherGurl]

I am on the UHC Choice Plus Plan. I was approved within the week, I believe surgery was scheduled in less than a month from seminar date.

[THICKCHICKTIA]

does anyone have atena hmo please tell me what i need to be prepared for

[JDru]

I have Aetna PPO...and I was approved in about 2 1/2 weeks. I made sure to get every single thing they needed and then some to make sure they couldn't deny me! It was a pretty quick, painless process.

Unfortunately, I've heard that Aetna HMO is tough! Have you called to see if your policy covers Lap-Band? I would do that first and if it's covered, then see what the exact criteria are and make an appt with your PCP as soon as you can. You'll need to do lots of blood tests, get a referral from your PCP and I had mine write a letter of support to include with my records. Also, start getting requests in for your medical records...it took me awhile to get them all together. Good luck!!

[Neal R.]

I had United Health Care. It was a breeze! I didn't have to get a referal from by PCP and he was not even involved with the process, not that he wasn't supportive. I went to my innitial consult and seminar and had surgery 5 weeks to the day later. The office did everything and had no problems with the insurance. I guess that is kudos to both the insurance and my doctor's office. I expected to have a hard time because of all the stories I have heard, but it was quite the opposite!

[Maggie63]

Health America denied my surgery in Dec 2005 (I did it anyway-self pay) I hired Walter and Kelley Linstrom from Obesity Law to assist in my final appreal (I appealed twice myself and lost). Health America overturned their decision, and reimbursed me for everything...including fills!!

I talked to my lawyer's office last week. After my win, several others appealed Health America and won. Health America has decided to COVER lapband effective some time in 2007 for federal employees

My advice to those of you fighting for coverage is DO NOT GIVE UP (I almost did after my second appeal). The BEST thing I ever did was hire Walter and Kelley for my final. They were wonderful.

You can reach them at:

walter@obesitylaw.com (walter@obesitylaw.com) or kelley@obesitylaw.com (kelley@obesitylaw.com)

P: (619) 656-5251
F: (619) 656-5254

I think (i hope) the tide is changing and more insurances will cover this life changing surgery.

[NurseTeresa]

Ok heres the latest scoop about working for a hospital who has a bariatric unit and wont pay for the surgery. They had insurance meetings this past week due to new year starting jan 1. These fools decided that they were gonna stick with UHC only(which sucks I want my Anthem back). The hospital decided to allow some bariatric surgeries but here is their stipulation.......We have to pay for all pre op testing, for the psych eval, for the surgeon, the anesthesiologist, any medications we need while there(pain, antibiotics, anti-nausea) all IV fluids etc. They only thing that they will pay for is $15,000 no more no less....and only for the RNY~! What kind of shit is that? The bariatric coordinator said that they had to fight like haities to just get that included. I said what about those of us that dont want RNY AND WANT BANDING...they said TOUGH! Its RNY OR NOT! I said at the amount that you all wont cover everyone would be better off to go to Mexico for approx $8000 or to another state who only charges $12,000 or so for the surgery. They then said no one in the area will fill for a mexican or out of state banded patient...I stood up and said YES DR CURRY IN CINCINNATI not an hour away will! With that I left. Guess I had them all talkin after I walked out. Please...can anyone tell me what sorta sense this offer makes? Even to have a RNY with insurance it is like $34,000 and up! UGHHHHHHHHHHHHHH I am so frustrated!