Why would a company deliberately exclude bariatric surgery from their benefit plan?

[fri38cy]

BC/BS is the underwriter for Educators Health Alliance surgery wasn't covered in our policy. But my possible hip and knee replacement surgery would be covered.
I self paid I took out a loan and paid for my surgery. I don't want to have knee and hip replacement surgery this was a better option for me.

The scale isn't moving as I would like but I will take my 32 pound loss. Because I will never be in the 300's again.
Just my 2 cents...You have to think about your boys taking care of your weight now so that you will be around for them later. This is not the easy way out for sure and anybody who believes that needs information on the surgery.
Good luck to you

[Lynnsey2121]

I've thought about the Open Enrollment option (our's is in December with an effective date of January 1). I think we'd have to run the numbers and see how much extra we'd be paying out of pocket for the cost of the premiums, not getting the "opt out" payment by my employer anymore, co-pays and costs for NUT visits and psychiatrist eval, plus the loss of paying some of my out of network doctors. And of course the time spent going through hoops to get the surgery covered....time off from work for those visits.

It's scary any way I look at it. I just wish my husband was more supportive. Just last night he said, you know, you should really eat better. Ummmm.....okay. Yeah. I know that. If I had that mastered by now, I wouldn't be considering WLS!

Thank you all for your support and suggestions. I know, my two baby boys need their mama, and I want to be there for them, and be active in their lives! Right now, I just feel like I'm doing the minimum to get by and I'm exhausted....

[dyberrah]

May I ask what the charge is for Mexico? I paid cash in Texas and it was a total of $14500 for the hospital and procedure and $70 for the pych evaluation. I saw the Dr in June and had it done July 15th. He would have done it in June but I needed to get my support group together.

From pick-up to drop-off at San Diego International, my cost was $4,200 USD. My husband stayed for free in the hospital and hotel rooms with me. Oh, and I had to buy my Omeprazole at a Mexican pharmacy - it probably cost about 5 bucks... (all other meds - pain killers, antibiotics, milk of magnesia based liquid antacid - plus a cd with footage of my leak test, were included).
Deb

[char602]

I am in the same boat. My insurance covers BMI of 40 or higher (mine is 35) they are considering my case. But my current quote for the surgery in Mexico is $4500 + I $250 airfare. Meeting the requirements for my insurance would run me about $2500. So I am paying twice as much but avoiding all the hoops and 1 year waiting game that I'd have with my insurance.

I'm not taking my husband with me for the same reason. He will put the kibosh on the whole thing if he is uncomfortable. But he is surprisingly supportive of the surgery due to my high blood pressure, sleep apnea and edema.

[ihavestandards]

I went alone but met friends who I met on this site who were having surgery around the same time as me. My mother had the surgery in Mexico and had fantastic results with no red tape and only paid 4300. I went to Mexico a week ago and paid 4400.00. That included everything I needed except for my plane fare. Luckily, I had just enough FF miles to fly first class both ways so my airfare was FREE! Mexico is not scary. I thought it would be but it was quite the opposite. I met so many new friends and have a close little support group!

[KimberlyH]

The year my husband's company began covering bariatric surgery (this was 8-ish years ago) and up to $10K of cosmetic surgery afterwards, nearly 100 people at our site of 1200 had some form of bariatric surgery. The next year, they stopped the benefit because "there are no centers of excellence" so for our protection. ::coughcough::

Of all of those people, only 3... *** 3 *** haven't gained most of it back or not lost much in the first place. One woman almost died on the operating table - she knew she had life/death issues with anesthesia - and had to have multiple corrections and such. She's now heavier than before and well over 300 pounds again.

How can I deny it was a failure for the company? An expensive one. Do I think it sucks eggs? ABSOLUTELY! But sadly enough, I can understand, though I'm still calling BS on the "centers of excellence stuff" especially since there are such centers now.

I went to Mexico in July and self-paid.

[zmdh39]

Why do some companies exclude bariatric surgery from their insurance coverage? I was so shocked when I called CIGNA to ask if my husband's insurance covered surgery and my jaw almost dropped to the floor when they said no. He has excellent insurance....I mean, they have UNLIMITED infertility coverage (IVF, no age limit, etc). Imagine my shock when they told me it bariatric surgery and obesity coverage is excluded. Sigh.....

Just venting. But also curious. My company which is a non profit has okay insurance, but does offer coverage for bariatric surgery. But I opted out of mine to go on his since his had out of network benefits and mine didn't. Also, my company gives me an opt out benefit payment every month for not being on our insurance. So, it was a no-brainer to go on his coverage since a couple of my doctors are out of network. But now, I'm looking at Mexico, but hubby is super unsupportive about that and it is scary to me to think if I have a complication, will CIGNA cover it back in the states?

I just feel so stuck.

Ok, your question actually has a very vast array of specific answers, but I will try and keep it short and simple. Insurance is such a complex industry, but like everything else in life is a business and businesses make decisions such as those for many reasons...but in the end all comes down to the bottom line...and that will be determined by SO many different factors.

Some insurance companies include bariatric benefits because, in theory, even though the surgery is costly, those companies look at long term revenue cost savings...so if you approve someone for surgery that has comorbities that cause health issues...they see it as the company will save money on future payouts on health complications associated with obesity.

On the other hand, some companies view the short term cost saving approach...so they would rather payout smaller increments of money to cover long term health issues...after all a person who has continual health problems is more likely to keep up with paying their premiums. Why pay for unlimited IVF, but not WLS?...well from a business standpoint...the end game of IVF is to create a new human being...and that little tike is going to need health insurance...so they are risking their capital to secure new future revenue streams.

Any business out there has the same goal, build revenue, expand their market, and continue doing so to last the test of time. Any business that hopes the last the test of time is going to be structure by a series of calculated decisions based on a million different factors. Take for example, the extensive pre-op requirements for many of the insurance companies that do cover the surgery...most people make the assumption that they require these things to the benefit of the patient, so they make them try and document diet attempts, send them to nutritional counseling, psych evaluations, etc. etc. Its a clever guise because it give people a sense of value and security, but I would bet anything that those decisions were not made solely base on the well being of the patient...not by a long shot...those are implementations put in place to give insurance companies an out to not pay for surgery, and having that out allows them to control their working cash flow.

Does it really make sense that a person that weighs 350 lbs, but has no comorbities, will get rejected? If the insurance companies were really making these requirements for the sole benefit of the person, then why on earth would the require people to develop serious, and sometimes irreversible health complications in order to have a chance at qualifying to have their surgery paid for? It all sounds rather cruel and crude to play with people's lives like that, but these are all realities of any business on this planet.

Another reason is a lot of the time the insurance that is offered through your company, as an employee, is designed different than private insurance you obtain outside of employment. Insurance for companies to give their employees are focused more at short term benefits.. 3-5 year benefits of the individual, since most likely you will be moving on and changing jobs.. thus changing insurance. They don't want to pay for your long term health (such as the battle against obesity) only for you to move to a new provider. If you go with private long term insurance then they feel you will be with them for life and so they are more open to weight loss surgery solutions. The reason US insurance companies don't offer insurance for out of country operations is because they don't don't receive any type of kickback when you leave the network.. aka they don't own stock in the facilities your getting treatment at or have 'preferred rates' with the providers.. so the 'keep it in they family' per say.

A lot of people assume having surgery in another country, MUST mean it is a lesser quality, or they are lesser doctors, or use lower quality equipment. I put in an incredible amount of research and investigation into making my surgical decision, I researched details that most people wouldn't have even thought about because I understand both business, and technology. There are good and bad doctors everywhere, research is the key, and I find it ironic that in America when it comes to having surgery most people don't research the surgeon at all...instead our surgical options tend to get limited and dictated by availability, insurance networks, etc.

I have written some articles for people in the research phase that you might find helpful, to both you and your husband, regardless of where you have your surgery. I know it is frustrating at times, but in my opinion my surgery was well worth it, and I would make the same choice over and over again. Good luck to you dear!

http://www.gastricsleeve.com/forum/q...ns-to-ask.html

http://www.gastricsleeve.com/forum/q...s-surgery.html

[Lynnsey2121]

Wow, thank you so much, zmdh39.....that was a lot of info, but very clear. It makes a lot of sense!

[zmdh39]

Wow, thank you so much, zmdh39.....that was a lot of info, but very clear. It makes a lot of sense!

You are very welcome. I have been in your shoes, my son was a little over a year old when I decided to have surgery. His dad, has never had a weight issue in his life, and was clueless to why I was so miserable, he was not crazy about the idea of me having surgery. It was the same response, eat better, work out and you will lose weight. When I was young I was very fit, very active, then my dad was diagnosed with cancer and I had to give up my extra curricular activities to get a job to support our family. Before I knew it I blew up to 210 lbs, I join my college's ROTC program to lost the weight...I think the lowest weight I achieve during my training was around 168...which of course I continued to gain and lose 100 times over...and always put more weight on. After having my son, weight loss was impossible for me. I hated myself because I just could lose the weight...so much to the point that I have very few pictures with my son from the time he was born, until I had my surgery because I hated cameras that much.

I knew surgery was the right decision for me, without question, but my spouse took some convincing. I won him over with my research, and information. Deep down he didn't want me to have surgery because he was terrified of the thought of raising our son on his own. Its a legitimate fear. The way I explained it to him is the same way that tell people when they asked how I made the decision to have surgery. I believe that we are all born with a predetermine expiration date, determined by God...whether we like it or not, he set the number of days that I have on this earth...when it is my time to go it is my time to go, and there is nothing that I can do to change it.

So working with that personal belief, when it is my time to go...it was just my time...so whether it be driving in my car, heat stroke, choking on a piece of steak, getting eaten by an escaped lion at the zoo, or on an OR table...the method in which I go is irrelevant. So I just made the personal decision, that life is random, I have no guarantee that I will wake up tomorrow, but there was no way I was going to allow obesity to be the method that took me out...nor was I going to allow it to ruin another day of my life, or take another precious moment away from me and my son. If my beliefs are right, and my days on this earth are limited, then I refused to waste another day of the time granted to me being miserable and hating myself.

Surgery is a very personal decision, it's not the easy way out, it is not for everyone, but if you decide it is for you, you need to research, educate yourself, and if possible your husband as well. Being confident in your decision, and being prepared as much as you possibly can...then you can rest at ease that you have done everything you can to have a successful surgery...the rest will be up to your surgeon and God. I hope the information is helpful, I wish you the best.

[judyvsgx2]

You still working for Dr Quinones? Glad all turned out well for you dear

[Lynnsey2121]

You still working for Dr Quinones? Glad all turned out well for you dear

Was this directed at me?

[judyvsgx2]

No ma'am Melanie is main Coordinator for Dr Q. Not directed at you. Send her a pm and she will put you in the Facebook group and change you from whoever to Dr Q. I believe she moved up in rank to someone else position.

Not directed at you dear, not one bit!

Work dinner with Bill, Stacy, and Melanie. All 3 live on the East Coast! Maybe they were just in the neighborhood!

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[judyvsgx2]

Shocked, no answer?

[SethP]

I spoke with several Doctors about this and this is how it was explained to me. The AVERAGE person changes insurance about every 3 years and the insurance company would not get to see the benefits of you losing the weight to recoup the cost of covering the procedure. I know that this is a crappy way to look at things and it is looking strictly at the business end but it is what it is. I had to suck it up and fincance it right here in the states and just the money I am saving each month on my medications has made it worth while. Godspeed on your decision.

[OneMoreLuckyGuy]

The easiest answer I can give you, is money. The sicker you are or become due to obesity and it's related co-morbidities, the more money insurance companies make off of you. More doctor appointments, more tests, and more prescriptions equals more money. Just that simple. Disgusting, isn't it?

How do insurance companies make more money off of someone that has more appointments, tests and prescriptions?