Insurance clause leaves lap band patients at risk

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by JANET ST. JAMES / WFAA-TV

wfaa.com

Posted on February 11, 2010 at 12:56 AM

Updated Thursday, Feb 11 at 2:01 PM

COPPELL — Weight loss surgery is often the chance of a lifetime for obese people who have failed every diet in the book.

While more insurance policies are covering these operations, many are also slipping new clauses into policies — clauses that often come as an expensive surprise to patients.

Pamela Mears says a Christmas party in 2007 was the first time people noticed her new figure. "Definitely people stopped to look, so it was kind of cool," she said.

Mears dropped 110 pounds after having lap band surgery that year. But in recent months, the weight has begun creeping back on.

"I worked really really hard to get where I was, and I don't want to see it go back to get where I was," she said.

Mears' gastric band slipped from its stomach-constricting position during a serious gallbladder attack that lasted months. An astonishing 25 gallstones were removed from her body.

At the time, doctors recommended repairs for "slippage of the gastric band" for medical reasons, but Mears' insurance company refused to pay for it.

"They'll have it removed, but they won't have it replaced," she said adding that the decision didn't make any sense to her.

The reason for the denial, Aetna claimed, is a clause becoming common in insurance policies.

Weight loss surgeries can be very expensive, costing between $10,000 and $30,000. "To endure fairness to all covered persons," this policy says, surgery for "morbid obesity" is limited to one per lifetime, per client.

"We battle this not infrequently," said Dr. James Davidson of Texas Health Dallas. Most patients don't know about the "one per lifetime" clause until they encounter a problem, he said; then they can't get it covered.

Dr. Davidson, a bariatric surgeon, said insurance companies are the ones who lose money by denying medically necessary surgeries to correct problems involving gastric bands.

"A few months later, if you don't put it in, they're going to gain their weight back," Dr. Davidson said. "So then it would be more expensive because then they're going to have the weight-related diseases back. Maybe their knee will start troubling them again, or their diabetes will start acting up."

After having gained 30 pounds already, Pamela Mears says she is already experiencing problems, worried again about high cholesterol and diabetes.

"I feel like I've been let down," she said.

After being contacted by News 8, Aetna re-examined Mears' case and found "...lap band slippage is considered a correction of a complication, and not a second bariatric surgery."

They have "overturned the denial" and have agreed to pay for her corrective surgery later this month.

Pamela Mears hopes her case could set a precedent, so other patients with gastric band problems won't see their hard-fought gains in the war on obesity... lost.

E-mail jstjames@wfaa.com

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