Insurance Do's and Don'ts

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Found this online about Insurance Do's and Don'ts

http://www.obesity.org/insurance.htm

Your health insurance company has a special interest in helping you

stay healthy…Your good health keeps healthcare costs down for

everyone. Being overweight raises your risk of costly health problems

such as diabetes. But losing that excess weight lowers the risk to

your health…producing potential savings for both you and your

insurance company.

It may surprise you then to discover that your health insurance plan

will not pay for weight-loss treatments. Most health insurance plans

will only pay for the costs of weight-related health problems after

they develop. Weight-loss treatments that prevent these problems in

the first place or reduce their severity are often not reimbursable.

You need to pay for them out of your own pocket.

Inadequate reimbursement for weight-loss treatment is an important

issue that you may want to bring to the attention of your health

insurance company and/or employer. To help you better communicate

your needs and concerns, this insurance web page offers

Basic information that you should know about obesity-how it's

diagnosed, its complications and costs, and the benefits of

treatment.

Valuable tips on how to request reimbursement for weight-loss

treatment from your health insurance company or employer.

Contact information for the American Obesity Association (AOA), which

can provide additional support.

Are you Obese?

" Obesity " is a word that means different things to different people.

To most people, an obese person is very overweight. But to doctors, a

person can be obese even if he or she is not extremely overweight.

That's because doctors usually define obesity as an excess of body

fat, not just excessive weight.

How can your doctor tell if you're obese? Measuring a person's body

fat is not easy. One of the best ways -weighing a person underwater -

can only be done in laboratories with special equipment. On the other

hand, doctors can measure the thickness of a person's skin folds

right in their own offices. This measurement of body fat, however, is

not always accurate.

Doctors often rely on weight-for-height tables. These tables provide

a range of acceptable weights for a person of a given height. Weights

that are outside the range carry a higher risk of death. While these

tables are a good " rule of thumb " measurement, they pose a number of

problems. They are outdated, for example, and do not provide

information on the risk of health problems other than death.

Increasingly, doctors are using a more " state-of-the-art " method

called the body mass index (BMI) to check for obesity. BMI is

calculated using a mathematical formula that includes a person's

weight and height measured in metric units (kilograms and meters). In

recent studies, BMI was used to estimate the risk of death and other

health problems in people who were obese. As a result, BMI is now

recommended by many obesity experts and key government agencies. You

may check your BMI by clicking here. The math and metric conversions

will be done for you, as well as calculate your BMI.

If your BMI is 27 kg/m squared or over, you are likely to be at

greater risk due to your weight.

The High Price of Obesity

If you're obese, you're not alone: so are a record number of other

Americans. As many as 1 in 3 adults in this country, or roughly 58

million people, are obese [JAMA 1994;272:205-211].

When it comes to being overweight, though, there's no safety in

numbers. Your weight can make you the target of discrimination in

your personal and professional life [Ann Intern Med 1985;103:1062-

1067]. And it can seriously jeopardize your health. Obesity can cause

heart disease [JAMA 1995;273:461-465]

diabetes [Am J Epidmiol 1990;132:501-513]

high blood pressure [N Engl J Med 1990;322:882-889]

high cholesterol [N Engl J Med 1990;322:882-889]

certain types of cancer [Ann Intern Med 1985;103 96pt 2):1034-1036]

gallbladder disease [Am J Clin Nutr 1992;55:652-658]

gout [Ann Intern Med 1993;119:655-660]

certain types of arthritis [Am J Clin Nutr 1992;55:652-658]

respiratory disease [int J Obesity 1995;19:410-418]

premature death [N Engl J Med 1995;333:677-685]

Every year, Americans spend almost $70 billion on these health

complications [Am J Clin Nutr 1992;55:503S-507S]. Another $33 billion

a year is spent on weight-loss products and programs, most of which

comes right out of consumers' pockets [Washington, DC: National

Academy Press 1995].

Losing Weight for Your Health's Sake

You can probably think of many reasons to lose weight, but none is

more important than improving your health. By losing weight, you can

reduce the risk of nearly all of obesity's complications. You can

also begin to bring down the cost of managing the complications of

your extra weight.

How much weight do you need to lose to reduce these risks? Good

news...even a modest amount (just 5% to 10% of your initial weight)

can really reduce your risk of serious health problems [int J Obesity

1992;16:397-415].

A Strong Support Network

To successfully manage your weight, you may rely on a number of

different resources. In addition to your own effort and commitment,

you may need the support of family, friends, and healthcare

professionals. Frequently, you also need money...money to purchase

weight-loss products or services, such as

diet foods or meal replacement products

at-home exercise equipment or membership at a health club

membership in a weight-loss program

behavioral or nutritional counseling

prescription drug therapy

gastric reduction surgery

These treatment approaches can be effective in controlling weight.

For this reason, your doctor may recommend that you try one or more

of them.

Your health insurance company, however, may be reluctant to pay for

the costs of your weight-loss treatment, even if it is recommended by

your doctor. The company may be unwilling to reimburse you for

obesity treatment costs for many reasons. For example, the company's

decision makers may not fully appreciate that obesity is a chronic

medical condition, like high blood pressure or high cholesterol. Or

they may not be convinced that a person will keep weight off long

enough to reduce complications and costs. It's also possible that the

company is not aware of your need for reimbursement of obesity

treatment costs.

Do's and Don'ts of Communicating with Your Insurance Company

If you would like to urge your health insurance company to help you

pay for weight-loss treatment, it's up to you to make your needs

known. It's up to you to ask for the company's help in improving your

chances of becoming a healthier person.

How do you ask for the support that you need? Here are some important

tips on how to start the wheels turning:

Do have confidence in the fairness of your request. Obesity is a

chronic medical problem with serious complications. Even modest

weight loss is likely to reduce your risk of complications, improve

your health, and reduce healthcare costs. You're well within your

rights as a valued customer to make this case to your insurance

company.

Do go through the proper channels within your insurance company. Many

health insurance companies offer you an " 800 " customer service number

that you can call with requests or complaints. In most cases, the

first person you contact at the insurance company is the customer

service representative. This person should be familiar with your

specific health plan.

If you would like to take your case beyond your insurer's customer

service representative, you may wish to speak to one or more of the

following individuals:

the Manager of Customer Service

the Director of Customer Service

the Marketing Director for new Products or Program Development

Your employer's health benefits manager may be able to put you in

contact with these individuals.

Don't hesitate to get your employer's health benefits department

involved on your behalf.

Discuss your needs with your health benefits manager at work. Request

his or her support in gaining reimbursement for your treatment. Your

health benefits manager may be very experienced in negotiating with

insurance companies, so you should carefully consider his or her

recommendations. Many employers will support your efforts to be

reimbursed for the treatment you need to stay healthy and productive.

Don't be confrontational, argumentative or hostile when making your

request or discussing your concerns. Do be assertive and persistent.

Maintain a " cool head " , while clearly and firmly expressing your

needs. Although you and your insurance company are both interested in

keeping you as healthy as possible, you may encounter some

resistance. Stick to your guns, even if company representatives are

uncooperative or impolite.

Do keep accurate and well-organized records of all communications

with your insurance company. Take careful notes when talking with

company employees by telephone. Record dates, times, and names and

keep copies of all written correspondence.

Do send the insurance company a written letter repeating your

concerns and requests after any phone conversation with one of its

representatives. Keep your communications simple and to the point.

Also, include all of the necessary information, such as your name,

policy number and other identification information. It's also a good

idea to enclose copies of receipts for unreimbursed treatments,

medical test results, and statements from your doctor.

Do ask your doctor to contact your health insurance company. Your

doctor should be sure to mention any medical problems associated with

your obesity as well as details of your treatment. The support of

your doctor can make a big difference.

Do some homework on the policies of other insurance companies. Some

insurance plans have begun to offer special discounts for weight-loss

programs. Others reimburse their members for the cost of the programs

if they work. Don't be afraid to mention the favorable policies of

competitors to your own insurance company.

Don't forget to follow up if you don't get the response you want the

first time. An insurance company representative may not be able to

provide you with the information that you need right away. If so, ask

that representative to follow up within a reasonable period.

Coping with Rejection

Despite your best efforts, your insurance company may still turn down

your request. Don't be discouraged. Rejected requests are common, but

often are not the final word. There are still several steps that you

can take, including:

Repeat your request. Ask your insurance company representative to

reconsider your request. In some companies, after your third request,

your case is automatically passed on to a higher authority. Being

persistent will show the company how important this issue is to you.

Appeal the decision to another level within the company. Each health

insurance plan may have several levels of appeal. This can be a time

consuming process. Keep in mind, though, that your first contacts

within the insurance company are not likely to be the company's real

decision makers. The appeals process may lead you to the very people

responsible for setting policy about reimbursement for weight-loss

treatments. Each health insurance plan may have several levels of

appeal. This can be a time consuming process. Keep in mind, though,

that your first contacts within the insurance company are not likely

to be the company's real decision makers. The appeals process may

lead you to the very people responsible for setting policy about

reimbursement for weight-loss treatments.

The individuals responsible for appeals are different in every

insurance company. But you may want to direct your appeal to one or

more of the following individuals:

a Medical Appeals Officer

A Case Management Nurse

the Medical Director

Keep your employer's health benefits manager informed. Share copies

or summaries of your communications, including rejection notices.

This will help the benefits manager stay familiar with your situation

if he or she chooses to discuss it with the health insurance company.

Contact your state's insurance commission in writing to describe your

needs and difficulties. Send copies or summaries of your

communications with the insurance company. Then, be sure to let your

insurance company know that you've contacted the commission on your

own behalf.

Write to state and federally elected officials who may be able to

assist you in the appeals process. Update them on your situation and

enlist their support on this important issue.

The American Obesity Association

Having the support of your doctor, employer, and perhaps even

government officials can be helpful when fighting for reimbursement

for weight-loss treatments. Another important ally in your fight is

the American Obesity Association (AOA).

The AOA is a nonprofit corporation that was founded in 1995 to

increase recognition of obesity as a disease of epidemic proportions.

The AOA is also dedicated to

encouraging individuals with obesity to obtain the best possible

medical care for their disease

overcoming the stigma attached to obesity

achieving greater research of obesity as a disease

urging health insurance companies and government agencies responsible

for program such as Medicare to treat obesity as they do other

diseases.

The AOA is an important source of information on issues related to

obesity. For example, it can provide additional guidance on how to

approach your insurance company when asking for reimbursement.

To receive additional information and support from the AOA, you can

join the organization by clicking on the " Join " link below. In

exchange for a $15 annual membership fee, you will receive the AOA

report four times a year and special communications as needed. Take

advantage of this important resource -it can be a key to your success!