Insurance Coverage for Weight Loss Surgery
Information from the book
“A Complete Guide to Obesity Surgery” by Bryan G. Woodward,
Master of Public Health in Nutrition - Licensed Clinical Exercise Physiologist and
Member of the American Society of Bariatric Surgery
Insurance coverage for WLS is inconsistent and insurance companies can be totally illogical.
Medical insurance policies can vary among the various insurers and coverage can vary a lot within each insurance company. Some insurance companies will even customize their coverage according to the needs of certain employers. These customized plans are done to be cost effective but come with a reduction in coverage for certain benefits. Before you “take the time off from work” or “spend a day at a surgeon’s office” it would be a good idea to call your insurance company’s customer service department and ask about your coverage as it pertains to bariatric or surgery for morbid obesity. But before you place that call be ready to give your insurance representative your policy number and the type of policy you have with their company. This information is usually on the insurance card you were given when you signed up for coverage.
You can phrase your question something like this: “I would like to know my policy benefits regarding the surgerical treatment of morbid obesity, specifically weight loss surgery/gastric bypass that my Primary Care Physician/doctor feels is medically necessary for me.”
The answer you want and need to hear is “if medical necessity is determined then you appear to have benefits”.
When you visit your surgeon’s office you will be asked to provide proof of any insurance coverage. This information would again be on your insurance card. Your card should have the name of your insurance company, policy ID number, group number, telephone number(s), and address info necessary to verify coverage. A member of your surgeon’s staff will contact the insurance company and verify your benefits. Getting approval for treatment can take time. Sometimes up to 3 to 4 months, so don’t get discouraged if you don’t hear something right away. But sorry to say, insurance companies will love to use delay tactics involving misfiled or seemly lost correspondence from your doctor, surgeon, and even you. They think if they delay long enough you will get tired and go away. Don’t do it, make copies of everything before sending it to the insurance company and if need be your doctor or surgeon will gladly resend or compose new request for approval letters.
Unfortunately, most times insurance companies are trained to say “NO”. Denial of treatment can and has occurred many times. If you happen to be among the many who have been rejected for bariatric treatment don’t take it laying down. This is not the time to crawl into a hole of self-pity and have a “poor me” attitude. Stand up and fight. The first thing to do is to find out the reason you were denied. You and your surgeon should ask for detailed explanation(s) for denials and have it writing. And most important, remember to “document everything”. Start a log and list each piece of evidence. Letters from the insurance company, dates, times, phone calls to and from your insurance company and who you spoke to. You may need this information weeks later if you are still fighting. Don't be rude or offensive to your insurance company’s representative's as this behavior will only jeopardize your chances for a successful outcome.
If it turns out you don’t have the benefits necessary for bariatric treatment. You can, if you are able to do so, accept full financial responsibility for your surgerical care and hospitalization. This option is rare as 90% of us need insurance coverage to cover such costs. Just don’t give up on trying to get your insurance company to pay. Become that “squeaky wheel” and do all in your power to obtain the help you need.
If you and your surgeon have done all you can and your insurance company is still being stubborn and unreasonable there are still options.
1. Contact the office of the Insurance Commissioner in the state you live and explain your situation to them. This has worked in many cases.
2. Also, you can contact an attorney experienced in insurance law. Hiring such a lawyer has helped countless patients receive benefits from their insurance companies. The noted attorney, Walter Lindstrom has fought enthusiastically for bariatric patients. He brings a unique outlook to his representation of the morbidly obese person, as he is a bariatric patient himself and as lost over 160 pounds. In 1996 Mr. Lindstrom established The Obesity Law and Advocacy Center and 100% of his law practice is devoted to representing people suffering from the disease of morbid obesity. You can contact him at:
The Obesity Law and Advocacy Center
2939 Alta View Drive, Suite 0-360
San Diego, CA. 92139
Email: Walter@obesitylaw.com or www.obesitylaw.com
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