Medical Treatment for Obesity.
Will Your Health Insurance Cover it?
© 2003 Jonni Good
Being overweight causes a lot of medical problems, and that can be expensive. Does that mean treatment for obesity is covered by your health insurance?
Not necessarily. In fact, probably not.
It may seem irrational to pay to treat the diseases caused by obesity, such as diabetes, high blood pressure, heart disease and some types of cancer - but not pay for weight loss drugs and surgery. In most cases, however, a diagnosis of obesity (and any treatment for this illness) is an "exclusion" of health insurance contracts.
I work for a health insurance company, and when I was a customer service representative I answered many questions about this issue. Callers were understandably frustrated when they found out they had to pay for this medical treatment themselves.
It doesn't mean you don't need the treatment, or that you can't have the treatment. It only means that your policy might not cover it.
Health insurance companies are more than willing to sell any coverage that companies are willing to pay for - but the more services we cover, the more expensive it gets. Most employers have to make hard choices when they purchase their group policies.
One problem is that each state mandates many services that must be included in every policy, and each year the number of mandated services goes up. In my state, for instance, pregnancy must be covered in every policy, even if the members are over 50 years old. Our neighboring state mandates all alternative treatments such as chiropractic, naturopathic and massage, whether the group wants them or not. These services must be paid for before any other services can be added.
These legal mandates often take up the full amount of a small company's health insurance budget. Additional "riders," such as those that would cover obesity or smoking cessation, are simply out of their economic reach.
In order to give basic coverage to as many of their employees as possible, most companies have to limit the number of things they can include in the group policy. Obesity is almost always left out.
Gastric Bypass Surgery, which is used in the treatment of morbid obesity, can cost from $17,000 to $34,000. If a diagnosis of obesity is an "exclusion" of the insurance contract, any complications of this surgery will also be excluded. According to the NIDDK website http://www.niddk.nih.gov/health/nutrit/pubs/gastric/gastricsurgery.htm from 10 to 20% of gastric bypass patients will have complications that require follow-up surgery.
While the newer types of surgery seem to have fewer risks, complications are still fairly common, and can be life-threatening. If you and your doctor are considering bariatric surgery, and your insurance does not cover the cost, you need to be sure you understand, and can afford, any potential complications.
How can you find out if you're covered for nutritional counseling, diet drugs or bariatric surgery? Call your health insurance company and ask them. The 800 number for your insurance company's customer service department should be on your ID card. If the treatment for obesity is covered, your doctor may still be required to submit a request for pre-authorization. The customer service representative you call will be able to find this information in your policy, and tell you if coverage is available, and how to find out if your qualified.
If your first call to your insurance company doesn't answer all your questions, or if the customer service representative's answers were too confusing, don't hesitate to call again. You will probably get a different representative, who may be able to explain things more clearly. However, if the contract says that obesity is an "exclusion of the contract", the representative can't change it.
You may, however, be allowed to appeal on the basis of medical necessity. The outcome of the appeal will depend on the wording of the policy that your employer (or you, if it's an individual policy) purchased. Ask your customer service representative for the details about how to appeal - they will probably mail forms to you and your doctor, and may give phone numbers to the appeal department. Your state's insurance commissioner may also give you advice.
If you and your union or fellow employees believe that obesity treatment would benefit a lot of people, you may be able to negotiate with your employer to have this service added to next year's policy. Unfortunately, with health costs rising all the time, many unions are struggling just to stay even with health care coverage - adding more benefits may be a very hard sell.
I know that several companies in my state are now experimenting by adding obesity coverage to their insurance contracts, to see if this reduces the overall cost of medical care for their members. Obesity does affect the bottom line of many companies because of the increased illnesses and absenteeism. But many people still see this as a lifestyle choice, and are not willing to increase everyone's health care costs for the benefit of a few employees.
The success of any obesity treatment, whether it is appetite suppressing drugs, nutritional counseling or bariatric surgery, eventually depends upon the patient's ability to adopt a healthy diet and exercise program. Perhaps the best way to convince your company to include obesity treatment in next year's health insurance policy would be to organize a weight loss "club," like the one discussed in the book "The Town that Lost a Ton." You would then have hard evidence that you and your fellow employees were serious about your health.
For more information, from the viewpoint of people who are not associated with the health insurance industry (I admit to some bias, because of my job), see the American Obesity Association website: http://www.obesity.org/subs/fastfacts/Obesity_Health_Insurance.shtml
Jonni is the author of Weight Loss: How to Keep Your Commitment - the program specifically designed to help you overcome your addiction to sugar and cravings for high-fat food. You can learn more about this unique program, which includes an informative e-book, one full month of follow-up audio emails, and an invitation to join our Weight Loss Success forum, at:
From the desk of Jonni Good
Author of Weight Loss: How to Keep Your Commitment
4820 SW Greensboro Way,
Beaverton, OR 97007