• York County 911 manager says insurance won't cover surgery

    By: Jason Stoogenke

    Updated:

    YORK COUNTY, S.C. - John Carter spent the last 27 years performing some sort of public service. He was the captain of a local rescue squad and an emergency diver. He now serves as the electronics and communications manager for York County 911.

    "He's helped a lot of people throughout the years," his wife, Keta, told Action 9.

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    Carter needs a hip replacement, but he said his doctors need him to lose weight first. He's about 400 pounds and says he needs to drop about 125 of that. He tried diet and exercise.

    "We change what we cook, what we eat, everything," Keta said. "Certainly tried the keto diet. Done paleo diets and, ultimately, just reduced the amount of intake," John said.

    But it hasn't been enough. Doctors recommend gastric sleeve surgery to take away roughly 85% of his stomach. One said Carter is an "excellent surgical candidate" for the surgery and recommended "him for this procedure."  Another said Carter would "benefit from bariatric surgery."  It would be "beneficial for him," said a third.

    "This had been their recommendation for a long time," John said.

    He's on South Carolina's State Health Plan, which will cover the hip surgery, but not the gastric sleeve one.

    "It's like you're just hung out to dry," Keta said. "And his career's going to get cut short without this surgery."

    Action 9 checked with multiple private insurers and most cover weight loss (bariatric) surgery under the right conditions.

    The South Carolina Public Employee Benefit Authority (PEBA) runs the State Health Plan. It offered the following statement to Action 9:

    "Bariatric surgery is not a covered benefit of the State Health Plan. As the plan sponsor for the State Health Plan, the South Carolina Public Employee Benefit Authority (PEBA) is responsible for providing the most comprehensive plan of benefits at a cost that is affordable to both individuals covered by the plan and their employers, who pay a portion of plan premiums. Keeping the plan affordable for everyone is one of our biggest challenges and, unfortunately, it results in certain services not being a covered benefit of the plan. There are other weight management benefits offered through the State Health Plan. The Naturally Slim program is available at no cost to members."

    But PEBA did seem to feel for Carter, saying, "This does not mean we do not believe in the intrinsic value of a particular service, but rather reflects the difficult decisions we have to make to maintain the affordability of the state's health insurance plan while providing the widest range of benefits possible to all individuals covered by the plan."

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    John plans to forge ahead and get the gastric sleeve surgery in June, despite the cost. He plans to pay out of pocket, which could run between $29,000 and $51,000. Emergency workers started a GoFundMe page for him.

    "The thing that I want most is that others who are suffering my same plight can get the insurance coverage," John said. "Change the way South Carolina views morbid obesity and the need for bariatric surgery and look at it positively for other state employees."

    "No one should have to come out of their pocket when they've been a dedicated employee for this number of years and they've had insurance coverage the whole entire time," Keta said.

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