My Struggles with Insurance Coverage (written on 6/22/08)

I just realized I never mentioned anything regarding the process of getting my surgery covered (or not covered), so here goes...

About 2 years ago, after my brother Jeff had his gastric bypass surgery, I decided to seriously start looking into it for myself. I had recently been laid off from my job (along with about a fourth of the other employees at the company I worked for), so I never had a chance to see if I was covered under that plan. A girl my husband worked with had the surgery about a year prior, so I thought I had it made. WRONG!!! I guess the benefits folks had decided to make a change to their UniCare policy to exclude any kind of weight loss surgery, unless certain very specific requirements were met. I decided to see if I could get through their process anyway since I met several of those requirements, and I had my surgeon's office submit all the paperwork for approval. Of course I was denied. By the language of the policy, I thought I might still have a chance with an appeal, so I consulted with my surgeon’s office for some guidance.

So... the appeal process began. I was denied a second time. We gathered more records and I had a sleep study done, because I was pretty sure I had sleep apnea (which I did). I figured with this documentation in my medical record, I'd have one more co-morbidity to add to the list, making my case stronger. We submitted everything again, and the folks who review the appeals came back with another denial, and didn't even acknowledge the new information we had submitted with the sleep study. Many of you know my frustration, since each one of these appeals takes a full 30 days or more. One let-down after another was just about all I could bear. The fourth time around, I happened to mention to the surgeon’s insurance coordinator that we were running short on time before my husband and I would be moving out of state. Unfortunately, this ended their enthusiasm for helping me, and I ran out of time to continue my fight, before getting too busy with our move…

So Erwin and I moved into our gorgeous new home in August 2007. He started a new job right away, and I started mine in November. I found out very quickly that both of our companies had specific exclusions in their policies about weight loss surgery or any treatment of obesity. Maybe through my experience they will come to see the long term benefits some day...
I came to the conclusion that I would either have to pay for this surgery out-of-pocket, or it would never happen for me. After nearly a year of waiting for our house in CA to sell, it finally did at the end of May, and I am using a portion of that money to pay for the surgery. I know it will be money well spent... I'm 35 and don't have children yet (even though I've been married 12-1/2 years). My biological clock is just ticking away, and the sooner I have this surgery, the sooner I can look forward to starting my family. There is no more time to waste on fighting the insurance companies, and waiting for more appeals to be denied... I'm expecting great things from myself and my surgeon, and I think because I'm having to pay for it, I will work that much harder to be successful.