My name is Chrissy. Some of you know me from years gone bye...HELLO!! Eveyone else...I tell a little about myself. I'm 36 mommy to five little boys and I've been married to my DH for 15 years. My weight has always been a battle for me.
Lately, I've really been thinking about WLS. I've been low-carbing for 10 months. I am really having a hard time with losing my weight. I'm seriously considering WLS. But I'm also scared. I called today to see if my DH's insurance would cover it and they said no. They don't cover anything for WL. Not even meds...meredia etc. But they do cover open heart surgery, diabetic meds, and high colestrol prescriptions. I am bummed that they didn't cover the WLS BUT.... is that where I have to stop with them? If my PCP thinks that WLS is a good idea can he influence the insurance company to change thier mind? I just hate the fact that they can tell me no....and we pay part of the premium!
Right now according to the Dr.s scale I weigh 299 I was up to 345 a couple of years ago. I don't know if I have any of the other things ( I'm sorry I don't know the correct terms) wrong with me that they look for. My Bp is in the normal/high range. I cant remember the top number but the bottom was 92. My Dr. said that was a little high but thought that it might be due to the fact that at the time I was in pain. I have a herniated disc. I don't have any idea what my sugar is or my cholestrol levels are. I do know my BMI is 47.
So, should I have a complete physical then drop this on my Dr? Or, should I find out if I can battle the ins. company and get their approval first?
All of this really does make me nervous. I'm worried that I'll be layed up and not able to take care of the kids....but back surgery could also be pending.
Advise me...what is my first step..especially since I know my ins. company will not pay for any WLS !!
Hi Chrissy! I would start with you doctor and tell him your situation. He/She will probably know the best way to proceed with the insurance company. If they still reject you, I would finance it. It's funny how most people will take out a loan for a 25,000 car, but wont take out a loan to pay for their health. Honestly, if I weren't approved on my insurance I was prepared to take a second mortgage on our house. I wanted and needed this that bad. I had my surgery not quite 2 weeks ago and I have already lost 25 lbs. My surgery was done laproscopically so I wasn't laid up at all. I even have a four year old! I only stayed overnight in the hospital. I had my surgery on a Monday, came home on a Tuesday and was out and about getting a pedicure on Thursday morning and back at work the next Monday. I know everyone might not do this well, but I just don't want you to think it's impossible. Sorry if it seems like I am rambling,but I wish you good luck in your journey!
I'll be honest with you and tell you that there is not a possible way that I could finance an operation. DH is the only one that works. We just make it as is. We don't have creadit cards...car payment or anything like that. We do have a mortgage and the usual utilities. Every penny that DH earns is accounted for. I use to work until I deceided to quit and homeschool the boys. I think most of our $$ is spent feeding the boys...LOL!! They really can pack it away
I think its a shame that DH and I pay some of our own costs for the ins. coverage but they are able to tell us what they will and will not cover?!?
hi chrissy!!! you've always been one of my idols... homeschooling 5 boys is no easy task!!! and you always do it with such a sense of humor...
you certainly have a problem on your hands. first, it IS frustrating that we pay for insurance and it won't do what we want. i'll spare you a whole long lecture about managed care, and employer health costs and this bizarre idea that the two groups have that we - the members - drive up costs because we want things. it's almost like they think we wake up one morning and say to ourselves 'let me have some icky invasive procedure that'll keep me in the hospital for a few days, lay me up for 6 weeks, and require physical therapy as well.'
few people would do that , and they have names - and diagnoses - for those people who do. diseases like 'hypochondriasis,' and 'munchausen's syndrome.'
but i really got off track here.
my question for the insurance company would be 'why.' i've heard that some people ask that question and get answers like 'we'll only cover it for people with BMIs of X or higher and several comorbidities.' others get 'we just don't.'
and if you don't get a decent answer, i'd suggest writing to the president of the company, or changing insurance companies. some employers offer more than one choice, with differences in $$$ to the employee.
the other thing about refinancing or taking out a loan is that the interest would be tax deductible. that savings can help a little bit.
or you could go to mexico as so many people have. not that i see you doing that... but it's still a choice.
bottom line, i'd think making LOTS of noise with the company might be the most reasonable approach for you. you have five boys!!! you HAVE TO BE used to dealing with bickering!!!!
Hi Chrissy! Do you have a copy of your company plan for insurance? the person who told you "no, no coverage for anything diet related" could be wrong. Get a copy of your plan and look for these two words....."medically necessary." My husband's plan excluded anything weight loss related unless "medically necessary." I used to say at 360, high blood pressure and diabetic.....I was the picture of medically necessary. Even without the comorbids, your BMI would qualify you.
Don't give up...........even if you find without a doubt that your husband's insuracne plan has an airtight exclusion for wls, you could always change plans and try again and lobby for it to change (as Jiff said above)
Working as a medical biller for several year, I know from experience that what you are told on the phone when you inquire about coverage, and what is actually covered can be several miles apart. #1 it depends on WHO you talk to #2 they talk in generalities, every company's individual plans are different. #3 everything can be changed by the approval of the medical director of the policy.
My first piece of advice would to be to an appointment with the surgeon, and let them work out the insurance approval for you. When ole Alvin went to the informational seminar when he first started thinking about WLS he filled out all the necessary paperwork necessary to start the approval process, and the doctors office worked through it. They would call and ask questions from us as needed, but they got it approved, and then he went in for the first actual appointment with the surgeon. I worked for a group of rheumatologists and we did a lot of very expensive procedures, and our doc's would not do anything unless we had written approval beforehand, and I know it's a long time consuming process, but it can be done.
Thanks for the encouragement ladies. In the past my weight has bothered me but it seems like it's really starting to get to me. As I get older ( I'm 36) I notice that I'm getting more aches and pains.
I hate hearing no as an answer....LOL!!! I guess I'm acting like a child. Alot of things that I've gotten out of life that were really good I had to fight tooth and nail to get. I just hate having to fight for everything!
I'm still doing Atkins. I won't go off of that because I am seeing progress..just not on the scale. My clothes are getting a litte bigger so there is hope! I'm just sick of being so fat!
Next time I have to see the Dr. I'm going to mention this to her and see what she thinks. I know it's only a matter of a few weeks until I'll see her especailly since my back is so touchy. I am also planning on starting an exercise routine. I need to do this. Maybe it will speed the scale along and get my back in better shape. I'm thinking about getting a tredmill but I don't know the first thing about them. Where I live it's nice and I could walk but I'd have to bring all the boys along with me....I could wait until DH get's home and walk in the evenings but I don't really like walking out here in the dark. We have bears and other critters that might view me as a midnight morsel...
P.S. I will also e-mail my hubby ins. co. and see if I can get a written copy of their plan. We were never given one to my knowledge. So, I'll start there.
Hi Chrissy,
I remember you from the old days. Nice to see you again!
Does your husband work at a company big enough to offer more than one insurance company option? Fortunately, mine does and I was able to change insurance plans this January. Maybe that option is available to you too? We pay a higher copay now and prescriptions cost more, but it was definitely worth switching.
No, They only offer one type of insurance. They just got rid of Aetna and now we have First Health. Does any one here know anything about First Health?
In Texas First Health was one of the better plans, at least as paying a Rheumotologist went. They paid a lot of lab fees that other companys would not pay, but as I said all plans are different.
I decided to see what I could find about First Health on the net and right there on their site is a whole article about a new Bariatric (WLS) program where the doctors are highly trained, and the hospitals are supposed to be good and the doctors have an unusually good outcome with their surgeries. The doctors in the plans and the hospitals are working with First Health to "lower" costs, but the article tells you what they pay for and why. Here is the link
But don't forget to read the fine print, every plan is different, and some plans specifically disallow different things, but it sound very encouraging.
Very Curious
