Many insurance plans do not provide reimbursement for weight loss treatment. According to many practitioners, few private insurance indemnity plans or managed care organizations appear to cover the costs of obesity treatment regardless of whether the service is a medically supervised program of weight reduction or maintenance, nutrition counseling, surgery or a pharmaceutical product. The countless number of available insurance plans and ever changing policies have made it difficult to assess the extent to which obesity treatment and prevention services are covered by third party insurers. More data and better tracking is necessary to determine the health needs of persons with obesity.

• A typical employer insurance plan could be similar to that of Wal-Mart. Benefits listed in their employee benefits booklet (1999) as “not payable for treatment or services” include charges from:
  • medications and diet supplements which result from diet programs,

  • appetite control,

  • weight control, and

  • treatment of obesity or morbid obesity, including gastric bypasses and stapling procedures even if the participant has other health conditions which might be helped by the reduction of weight.

• The Pharmacy Benefit Management Institute reports that appetite suppression products have been excluded by more than 80% of employers, according to a sample of 375 companies representing almost 12 million beneficiaries in 1998. This represented the third straight year that the exclusion rate was above 80%. Decisions to exclude these products increased after the 1996 introduction of Redux^TM by Wyeth-Ayerst.

• The AOA’s brochure, Weight Management and Health Insurance, offers suggestions on requesting reimbursement for weight loss treatment from health insurance companies or employers, and appealing denials for coverage.

Letters to AOA Regarding Insurance Coverage and Obesity

The AOA receives many calls and letters from persons with obesity seeking help with denied insurance claims for obesity treatment. Excerpts from actual letters sent to AOA, as shown below, indicates how devastating this situation can be.

Letter 1

• My HMO is killing me!!!!!! Please Help Me!!!!!!!!!

  I am a 39 year old mother, that is disabled and in a wheelchair for life. My doctor has told me that I need a "Medically Necessary" surgery, and that I will die an early death without it. The catch is, my HMO will not pay for this surgery. I have been through three appeals already, and I went through a "State Board of Appeals" last Monday. I lost again. The reason I lost is: the state claims they cannot make the HMO pay for my surgery because there is no law saying that the insurance must pay for a "Medically Necessary" surgery.

  I think people should know that there is no law, and that their insurance company can let them die if they so choose. Please help me. The insurance company is [omitted]. They claim this surgery is not a covered service. My question is: Is death a covered service? I have no other insurance, and I can’t pay for the surgery myself. I have no other hope. You are my only hope. Please Help Me!!!!

  I am not able to get Medicare because I did not have enough credits. I had to stay at home and take care of my disabled daughter that was born with a birth defect. I am not able to get Medicaid because my husband, who is a teacher, makes just over $75 the limit for Medicaid. I have fallen in a crack. Please help me!!

Letter 2

• Please help [my friend]. She is a wonderful person, deserving the very best in life, but instead she is suffering terribly. [She] is a resident of Florida, where she has health insurance from [omitted]. She is confined to a wheelchair, and they won’t pay for her to get it fixed. She is in constant pain, and they won’t pay for her pain management treatments or medications.

  She is morbidly obese and suffers from the associated problems of sleep apnea, high blood pressure, urinary stress incontinence, asthma, arthritis, joint pain, high cholesterol, and acid reflux. Her personal physician, her surgeon, and other specialists have all recommended that she obtain a gastric bypass operation to help her lose her life-threatening excess weight, and to alleviate the other health problems she has, but the insurance company will not pay for this surgery either!!

  She has fought them all the way to the Florida State Board of Appeals, where the state ordered the HMO to pay for her surgery, only to reverse their decision days later due to an appeal by the HMO. This is so awful for her, literally dying of her ailments, while she fights an uphill battle against an uncaring beauracracy. This HMO apparently has no sense of humanity, but perhaps they have a sense of humiliation. That is why she needs to bring her story to the attention of the public. This exposure could also be very beneficial to other morbidly obese individuals who are unaware of the availability of this life-saving treatment, and it might help congress pass the Patients’ Bill of Rights, which is under consideration in the Senate.