Health Insurance Issues-Las Vegas

[JustJuraLV]

@Larra @DianaCox

I am currently insured through a private health insurance, Clark County Teachers Health Trust, for licensed employees of our school district in Las Vegas, NV. We have no other choices for health insurance. I have been out on disability since Nov. 8th, 2016 and paying for my health insurance through COBRA. Before the end of 2016 I looked into buying my own health insurance privately through a big name carrier like United, BCBS, etc., but found that I couldnt purchase anything that would cover me and the surgery I need (hernia repair with component separation/mesh placement). I was told that the National Market was taken away. I had my DS back in 2002 and have had several other surgeries and procedures since then, however, anything related to bariatric surgery is considered an exclusion. This is what I was sent regarding my last surgery was in Dec. 2015 by Dr. K in CA. It was initially just for a feeding tube placement, but he ended up having to go in and found I had a severe blockage and hernia that had to be repaired as well.

"Please be aware that bariatric surgery is not a covered benefit under the Teachers Health Trust PPO Benefit Plan, and any complications incurred as a result of that non-covered surgery are also excluded. Please refer to your Summary Plan Document, Non-Covered Expense # 4, which indicates that the following is a non-covered expense: Expenses for bariatric surgery, including treatment of the complications resulting from bariatric surgery. Any and all future expenses for any complications directly related to your previous bariatric surgery are also not covered."

Now I'm in currently in another situation where I have a hernia that is causing an obstruction and Dr. K said my colon appears to be redundant and needs to be looked at.

Do I have a chance fighting this with an appeal (I know my health insurance will deny procedure)?

Jura in Las Vegas

 

[DianaCox]

Is it too late to sign up with an ACA plan? Last day is Tuesday, January 31st. Platinum plan with high premiums and low deductibles?

 

[Clematis]

Uh, how is hernia repair STRICTLY related to WLS?? Aren't hernias common with any significant weight loss? Can insurance company PROVE hernias and blockages are as a result of WLS?

 

[southernlady]

Is it too late to sign up with an ACA plan? Last day is Tuesday, January 31st. Platinum plan with high premiums and low deductibles?

If she has an employer based plan, the ACA is unavailable as dh (who use to work for a health insurance agency) understands. BUT call an agent tomorrow and ask.

 

[JustJuraLV]

Is it too late to sign up with an ACA plan? Last day is Tuesday, January 31st. Platinum plan with high premiums and low deductibles?

I was told my a health insurance broker in Vegas that there weren't any of those types of plans available to me. Who could I call? If I could, I absolutely would...I just need to be guaranteed there are no exclusions.

Btw, Thank you for your response. If I can get it done, I will. I'm currently paying $600/mo for Cobra

 

[JustJuraLV]

If she has an employer based plan, the ACA is unavailable as dh (who use to work for a health insurance agency) understands. BUT call an agent tomorrow and ask.

The Teachers Health Trust is a private funded insurance so they fit into a loophole by ACA in a grandfathered clause that says, b/c it was in existence before 2010 they can have exclusions to things like bariatric surgery or complications after.

I never started having major health issues until I had a failed 3 disk lumbar fusion in 2013. I am so frustrated, b/c my disability company is saying they will cut me off if I don't have surgery by next month, yet I have to fight this health insurance battle and I don't feel well, but they expect me to return to work despite Dr K, saying I am unable to at this time.

I had a feeding tube placed and an obstruction/internal hernia in Dec. 2015. Prior to this surgery, my health insurance company (Teacher's Health Trust) sent me a letter stating that a feeding tube did not require prior auth. Dr. K attempted to place the feeding tube, but when he did he had problems and had to open me up and that's when he found the obstruction and hernia. That particular situation was an emergency. I woke up in recovery and was told that I had been in surgery for 3.5 hours instead of the hour that was planned, and I ended up being in the hospital for 9 days vs. the under 24 hours that Dr. K and I had discussed prior to surgery. I was very ill, malnourished, and had a mess internally.

I just recovered from that surgery in April 2016 and had started back to work after being off 12 weeks, when I got a call that my mother had been put in the hospital. I had to take a LOA with no pay from work and ended up being with my mom for 3 straight weeks in the hospital before she passed. I came back to Las Vegas to mentally recover and planned another trip to the midwest for the summer. Once again, I headed back home in July 2016 to go through my mom's personal things and my 57-year-old sister was hospitalized. Ironically my sister had a feeding tube placed as she was very malnourished and had a bowel obstruction. She WAS NOT a bariatric patient. Two weeks later she passed away so once again I had to plan a funeral and help my family through such a tragic event.

I say all this to say that I have been through HELL the last two years and now I'm dealing with yet another hernia that is causing an obstruction. I never know if I'm going to be in the bathroom nonstop with vomitting or diarrhea. Some days I'm constipated and can't seem to go or ever completely eliminate which I believe is causing me to have a redundant colon as well. Some days I'm in bed, a majority of the time, b/c I have such horrible abdominal pains that I can't stand and/or walk. I end up in the fetal position curled up hoping it will pass. I feel like crap, have no energy, need an iron infusion, and need to have this surgery, but I'm facing adversity every step of the way. I attempted to go to a gastro Dr. here locally that my PCP referred me to. The local gastro Dr said, "I will not do surgery on you as you don't have all of your original parts. From the looks of your labwork, you will need TPN or a feeding tube for the rest of your life. I don't deal with feeding tubes or TPN, so I would have to refer you out."

I'm 40 years old and have a daughter to raise. I can't live my life hooked up to a feeding tube or TPN. So I went back to Dr. K, b/c I have yet to find a Dr. here locally that even understands the DS. The CT scan my PCP ordered due to what he could hear and see in his office in Sept 2016 was misread and stated that I had no visible hernias, while Dr. K was able to identify it with the naked eye and then saw it on the CT images. Dr K has attempted to contact the radiology dept in Las Vegas that read the images and file an addendum, however they have never returned his calls.

I'm tired, don't feel well, and simply want my life to get back to normal and right now I feel like all I hit is roadblocks. Not sure if there is any hope for me. I feel like I'll go bankrupt and find it completely criminal that I am required by law to have health insurance, but the health insurance I am offered through my employer and now COBRA has exclusions and so I can't receive the medical care I need.

Thanks to all for your encouraging words and advice/help.
Jura in LV

 

[JustJuraLV]

Uh, how is hernia repair STRICTLY related to WLS?? Aren't hernias common with any significant weight loss? Can insurance company PROVE hernias and blockages are as a result of WLS?

Yes, my 57 year old sister had an obstruction and feeding tube placed this last summer and was NOT a bariatric patient. She died two weeks later. It's so frustrating that health insurance companies can get by with these types of exclusions. I'm required by law to have coverage, but I can't get the surgery I need b/c they are protected by a grandfathered clause in the ACA that states something about private insurances can have exclusions if they were in place before 2010.

 

[DianaCox]

I'm thinking you need to get a real attorney in Nevada - this is above my pay grade. Do you have a union rep?

 

[southernlady]

@JustJuraLV Start here
Find an agency that handles ACA plans. Since you are on COBRA, you may be able to switch. Just do not drop your COBRA until/unless the ACA policy has kicked in.

 

[Larra]

I agree with Diana's advice, and have no additional advice to offer, I'm afraid. But even so, I wanted to express my sympathy for all you have gone through and are going through.

 

[DianaCox]

I don't understand your situation. If you are on disability and still employed, why would you have to be on COBRA? I thought COBRA was continuation of benefits after TERMINATION.

 

[JustJuraLV]

I don't understand your situation. If you are on disability and still employed, why would you have to be on COBRA? I thought COBRA was continuation of benefits after TERMINATION.

In Nov 2016 I had to take a medical LOA b/c I do not have sick time built up. I am currently unemployed and only insured through THT (COBRA).

 

[JustJuraLV]

I'm thinking you need to get a real attorney in Nevada - this is above my pay grade. Do you have a union rep?

I do not. Our Teacher's Union is the in bed with our health insurance company, which is why our health insurance changes two years ago got to this point. There are a multitude of people with horrible medical expenses and going bankrupt b/c of it, and our school board has done nothing. We are also a "right to work state".