Insurance

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#1 Post by **NoCPAPPleez** » Sat Jul 05, 2008 2:23 pm

Just curious -- Those of you who had your private insurance cover your braces and surgery, how does your insurance policy read? Does it totally exclude orthognathic surgery (but you successfully fought them anyway) or does it state that it is excluded unless 'medically necessary?"

Mine has a blanket exclusion. It lists as an exclusion "orthognathic surgery to correct retrognathia, apertognathia, prognathism, open-bite occlusion, or transverse skeletal deformities." In a separate section it states that dental surgery "related to orthodontic treatment" is excluded.

In yet another section, it states that dental surgery, non-accident, "to cover reconstruction or repair of the mouth caused by a congenital defect" is covered. Since my tiny chin and jaw is congenital (I have the baby pics to prove it), I thought maybe this was a loophole for me but am not too sure since it is specifically excluded in two other places.

So am I screwed in this deal or what?

#2 Post by **Arvensis** » Sat Jul 05, 2008 5:58 pm

From a legalese standpoint (which is basically what insurance language is), it sounds like the section on congenital defects refers to cleft pallet/cleft lip defects but in broad language so that if there is a minor defect not equivalent to a full cleft, etc, it would be covered, since it focuses on "repairs to the mouth" vs. jaw relationship. A full exclusion means they don't look at whether it is congenital or not, medically necessary or not, just whether its type X.

Sorry not to bring good news. Mine was excluded specifically too.

#3 Post by **NoCPAPPleez** » Sat Jul 05, 2008 6:12 pm

Thank you for your reply, Arvenis.

So did you try fighting them for the coverage? I know there are attorneys who specialize in this.

#4 Post by **Arvensis** » Sat Jul 05, 2008 8:36 pm

From what I have heard it's not worth it to fight it - my insurance is through my husband's work, so an exclusion is an exclusion - it's in the policy, and it's based on what his work selected. We did harass the HR people at his work, to no effect. I can't see an attorney in this area getting much out of it either; you'd be paying legal fees for something very uncommon to get reversed in a legal setting in the first place, and jaw surgery isn't like some procedures that get rejected for being too medically risky and so forth. The thing is, if it was something that was a judgment call, like whether or not a procedure for cancer was worth the cost benefit or likely to succeed, that would be a jury issue possibly, but for an outright contractual exclusion, not really much expected out of that in a court besides summary judgment for the insurance co. since there isn't a question of whether it is right or not right to exclude, just that it's contractually excluded. A court can't tell an insurance company to modify its contract; it has to uphold the language of the contract unless a specific situation (like fraud) exists that would let the court modify the agreement.

Might I add that these are just my opinions and I'm not a lawyer yet and nothing I am saying should be construed as a legal opinion about your case or whether you have a case so on and so forth and so forth:)

#5 Post by **NoCPAPPleez** » Sat Jul 05, 2008 9:26 pm

Actually, that's what I thought (a contract is a contract), but so many people are encouraging me to "fight!" I thought it was worth asking.

Thanks so much for your informative answer.

#6 Post by **Emaciated** » Sun Jul 06, 2008 10:48 am

This is taken directly from my initial rejection letter:

Upon reviewing the submitted information, I have determined that at this time, orthognathic surgery is/are not a covered benefit under the benefit plan. This determination is based upon the following plan language, found on page(s) 40 of the member's Certificate of Coverage.

Exclusions: Orthognathic surgery except in the following situation: 1) a jaw deformity resulting from facial trauma or cancer, or 2) a skeletal anomaly of either the maxillary or mandible that demonstrates a functional medical impairment such as one of the following a) inability to incise solid foods, b) choking on incompletely masticated solid foods c) damage to soft tissue during mastication, d) speech impediment determined to be due to the jaw deformity e) malnutrition and weight loss due to inadequate intake of secondary to the jaw deformity.

Based upon the information provided, the requested orthognathic procedures do not address a physiological functional deficit, therefore they are considered cosmetic. As such, they are not covered benefits under the plan.

I sent them a photo of my "inability to incise solid foods" and also got an evaluation from one of their speech therapists who included a report stating that I had a slight speech impediment due to my underbite. I also had my oral surgeon, orthodontist and dentist write letters stating that my bite is a mess and should be considered a "physiological functional deficit."

The reply from them was an approval letter.

#7 Post by **Arvensis** » Sun Jul 06, 2008 11:41 am

Karl - yours wasn't a blanket exclusion, you had to prove medical necessity according to the terms of your insurance. NoCPAPPleez's exclusion, if it is a blanket exclusion, means that the insurance company doesn't have to even determine if there is a medical necessity or not. Like mine, I sent in all this info on medical necessity, it didn't matter, since it was excluded either way. Fighting only helps if there is a judgment call to be made, IE medically necessary or not, etc.

NoCPAP, can you post the entire paragraph on exclusion from your plan? Does it give conditions like Karl's or is it just "under no circumstances these kind of corrections excluded" type?

#8 Post by **NoCPAPPleez** » Sun Jul 06, 2008 11:54 am

This is from the list of medical exclusions:

∅ Orthognathic surgery (jaw realignment surgery) to correct retrognathia, apertognathia, prognathism,
open bite malocclusion, or transverse skeletal deformities.

***********************************************************

That's pretty clear cut -- no ifs, ands, or buts.

OTOH, someone posted to one of the Yahoo groups that their policy had similar wording. Their OS got on the phone with the ins. co. and demanded to speak with someone above the customer service rep, and after that conversation his sugery was covered. However, one would have to assume that that patient had fairly severe problems with chewing, etc. which I do not have.

#9 Post by **NoCPAPPleez** » Sun Jul 06, 2008 2:21 pm

Kaiser Permanente Guidelines for Orthognathic Surgery (PDF file).

It appears that unless it is cosmetic, they will cover the surgery but not the braces. They will even cover a genioplasty!!

http://www.permanente.net/homepage/kaiser/pdf/45382.pdf