Policy Exclusion

As I mentioned before, my health insurance has an exclusion clause for weight loss surgery.  I find it particularly interesting because the research studies I've read have persuasively shown that surgical weight loss is more cost-effective than non-surgical weight loss for severe obesity (Picot, et al, 2009).  I am still actively researching the benefits and consequences of bariatric surgery, however what I've found so far supports weight loss surgery for morbidly obese patients to treat both the obesity and the co-morbid issues--many of which are improved and sometimes resolved due to the weight loss after surgery.

I am currently employed full-time in a school district.  We currently use HMO Louisiana, which is a subsidiary of Blue Cross Blue Shield.  In the limitations and exclusions section of my benefit plan booklet, it states the following:

"Regardless of Medical Necessity, Benefits are not available for any of the following, except as specifically provided for in this Benefit Plan:
a. weight reduction programs;
b. removal of excess fat or skin, regardless of Medical Necessity, or services at a health spa or similar facility; or
c. obesity or morbid obesity, regardless of Medical Necessity."

So there you have it.  My question is, if the research points to the cost effectiveness of weight loss surgery, why will my HMO not cover the surgery?  I already have knee and joint issues, depression, high blood pressure, a history of heart disease, and insulin resistance.  Over my career I expect these issues to cost tens of thousands of dollars--if not hundreds of thousands of dollars.  At $15,000, I would think that bariatric surgery is an absolute deal if it will most likely significantly reduce my cost to my insurance company over the next 10-25 years.

Why not cover surgical weight loss when warranted?  My guess (but I would love to hear a different opinion--especially one backed up by research) is that society tends to place a lot of blame and disgust towards people who are obese.  People who have not experienced severe obesity don't always understand that it is not simply a problem of willpower or choice.  Do you honestly believe that I would choose to be this way?  Yes, sometimes I make poor choices.  For the most part, though, I try to make better choices.  I feel the self-doubt and pain of my own obesity.  I feel all the shame and disgust that others do towards me.  And I live in it every day of my life.  I do not want to be this way, and I have tried many, many, many times to be different, but nothing seems to work well for me.

I have an appointment to see my primary care physician in about a week and will address many of these concerns with him.  I will try to move forward with my insurance, even with the exclusion.  But even so I will also begin to save up for the procedure myself.  It is expensive to come out of pocket, and it will take me a long time to save it up, but I am worth it.  I know that inside of myself I am beautiful and I am worthy of being the person I really am.

Always Beautiful,
Kelly

Picot J, Jones J, Colquitt JL, Gospodarevskaya E, Loveman E, Baxter L, et al. The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation Health Technol Assess2009;13(41). [PubMed]