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Gastric bypass insurance coverage

TA | January 1, 2010

Q: My wife was considering gastric bypass. The waiting period is a year and she must follow a certain plan created for this procedure. Would this surgery be considered covered? My mother-in-law has had supplemental insurance for years, and she highly recommends it. We are just trying to sort things out like costs and what company is the best value.

A: There is no generalized procedure for getting insurance pre-approval for gastric bypass surgery under a major medical policy and so coverage is handled by each insurance company on a case-by-case basis. Some insurers are pretty liberal in offering coverage and others have taken an absolute stand that gastric bypass procedures causes more medical problems than they solve. Some regional managed care companies have a strong reputation for leadership in this field of treatment - check with your doctor's office to ask which insurers have provided the best coverage in your area.

The best scenario would be to have a major medical insurance that is known to cover gastric bypass in your local area combined with a supplemental insurance to help with the high out-of-pocket costs. Both should be in force well in advance (6-12 months, depending on where you live and your prior coverage) of your planned surgery. Any of the supplemental insurance plans listed at MedSave.com can be used in combination to boost the overall level of coverage. Other than the waiting period discussed below, all of the supplemental insurance policies will cover gastric bypass.

In any case, you should let the professionals office and hospital staff handle the pre-approval under you major medical insurance. Although you are entitled to handle pre-approval yourself, this situation is not a do-it-yourself project. The staff at doctors' offices and hospitals handle pre-approval procedures for these procedures on a daily basis and so they are experts on it. In the event the procedure is not approved then your doctor may wish to discuss alternate treatment that is less invasive.

Regardless of this insurance you choose, please consider three things:
1) The recommendation of gastric bypass indicates a pre-existing medical condition (obesity and possibly other conditions) and you will be subject the the waiting periods for pre-existing conditions before coverage is available. This applies to all types of insurance.

2) Supplemental insurance does not require pre-approval for any treatment so, for example, if you have a policy that provides $1000 per day in addition to your other benefits, then that is what you can count on, presuming that note #1 above is addressed. For this reason, it is common for people contemplating gastric bypass surgery to add a supplemental hospital insurance like Value Health. Start it now and do not wait until surgery is scheduled.

3) The percentage of gastric bypass patients who need follow-up surgical procedures is relatively high compared to other surgical procedures. Keep your major medical insurance a high priority in your budget and do not lapse this insurance after the initial procedure.


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