Question
Hi Tricia,
6 years ago, I had adjustable gastric banding for weight loss which was covered by my insurance company (it is my husband's groups health plan). I lost weight, then suffered a complication that required removal of the band and placement of another (again, covered by insurance). That was two years ago. This band has never worked. I have suffered severe reflux with ulcers. I sought a second opinion from a highly respected weight loss surgeon, who, after testing, states that this band needs to be removed. He is also recommending a vertical sleeve gastrectomy be done at the same time, as this will not have the complication (slippage) that occurs sometimes with the band. It is also more successful than the band.
My insurance company has agreed to pay for the lap band removal, but not for the vertical sleeve gastrectomy. Any procedure related to weight loss is excluded in the policy. My husband and I did not have any options when choosing our current health plan. His employer changed insurance companies in April and we were given notification after the change was made. I have gained back all of the weight I lost and remain morbidly obese, with high blood pressure, leg pain, and depression.
I am going to file an appeal with the insurance company. Is there any chance that they will cover this procedure? Do insurance companies ever pay for procedures that they have excluded on their policies?
Thank you for your time,
Robin
Answer
Hi Robin!
Usually exclusions are in policies to tell a subscriber up front they will not pay for specific procedures. As long as they are telling you they do not have to pay and probably most times they will not.
You can appeal however I doubt they will pay.
Tricia
