"We accept your premiums and deny your claims"
(motto of the insurance industry …. also their business model)
If you are dealing with an insurance company regarding treatment for cleft palate, here are some tips:
1. Don’t accept a denial.
2. Don’t accept it when your doctor says "the insurance company probably won’t cover it." You tell the doctor to prescribe the treatment and that you will deal with the insurance company!
3. Ask for the "case manager" at the insurance company. The person you are talking to _ who denied the treatment _ probably does not know much about the condition.
4. Make notes about every conversation with the insurer:
- get name
- date and time
- summary of conversation
5. Don’t be an adversary. Seek out someone who cares. Most do but they are defensive.
6. Insurance policies are contracts and the language in the contract controls in disputes. If the policy has the phrase "genetic defects" it may mandate coverage. This is often not in the literature about the policy. Insist that they check the actual policy language and coverage documents.
7. Denials are often an attempt to get you to go away. This is your child! Don’t go away. Ask for the documents that cover appeals and the number to call to institute an appeal. Insurance companies deny valid claims because they know that most people will believe them …. and go away. That’s not you!
8. If they tell you that the appeal will be submitted to a "reviewer" _ usually a doctor _ know that this person is almost always on their payroll. Ask that question.
9. Insurance companies are regulated because of their abysmal record of being dishonest with patients. Call the insurance commissioner in your state or check with the National Association of Insurance Commissioners (www.naic.org).
10. DENIED: "the treatment is cosmetic". Here is what the Cleft Palate Foundation says about "cosmetic" denials:
Adults may have a particularly difficult time winning an appeal on this issue. Again, be sure you are dealing with a person with a medical background at the insurance company (such as a case manager), and have your primary care provider write a letter on your behalf stating the medical benefits of the treatment. Emphasize that the requested procedures will help restore correct function to the affected area of the body, not just influence self-esteem. Provide pictures if necessary. You may request information about cleft and craniofacial birth defects from the Cleft Palate Foundation at 1-800-24-CLEFT or www.cleftline.org to help educate your insurance company on necessary treatment for individuals born with cleft or craniofacial birth defects.
Good advice! Follow it.
11. DENIED: Dental
Again the Cleft Palate Foundation has great advice:
Try to have your case reviewed by a plastic surgeon. Obtain letters of support from your surgeon,
team, and primary care physician, stating the medical need for these procedures. In fact, letters from the dentist or orthodontist may not be the most helpful to your case. Using descriptive terms like “presurgical maxillary orthopedics” to describe orthodontic palatal expansion may keep the procedure from sounding “dental.” Fight for one procedure at a time. In all instances, it may help to demonstrate to the insurance company that paying for one procedure now may eliminate the need for future procedures, thus saving the company money in the long run. Be aware that medical insurers sometimes classify the dental and speech problems associated with cleft or craniofacial birth defects as “secondary conditions.” It is important to demonstrate that these treatment needs are a direct result of the initial condition and that they are not just consequences of earlier surgeries. Emphasize that these procedures are necessary to ensure the best possible outcome for the patient.
12. DENIED: Pre-existing condition:
The purpose of the pre-existing condition clause is to prevent people from signing up for health insurance right before treatment is needed for a medical condition they have had for a long time. Do not allow your insurance policies to lapse, because it puts you at risk for this type of denial. If an insurance company you want to use refuses to take you as a client, ask if the company has a period of “open enrollment” during which you can sign up for coverage. Be aware that there may be a waiting period before medical treatment will be covered for a pre-existing condition. Insurance regulations differ from one state to the next, so check with your cleft palate
team or your state’s insurance commission about laws governing pre-existing conditions in your state.
13. A team approach is important. If the insurance company denies team of complimentary care find out if your
14. If your insurance comes from your job, contact your employer and tell them that the insurance provided is not taking care of your child.
15. You may have legal rights to get coverage for treatment from other sources. Contact a lawyer to learn your rights. Medications that cause Cleft Palate may provide your child with coverage through a claim against the drug manufacturer. I refer clients who contact me in Hawaii, to the Anapol, Schwartz law firm in Philadelphia. Mike Monheit is the contact you should ask for at Anapol, Schwartz.
If you have any questions about your legal rights take a look at Mike Monheit’s great article on insurance coverage:
Cleft Palate Surgery – Insurance Coverage Basics by Michael Monheit.
A resident of Honolulu, Hawaii, Wayne Parson is an Injury Attorney that has dedicate his life to improving the delivery of justice to the people of his community and throughout the United States. He is driven to make sure that the wrongful, careless or negligent behavior that caused his clients' injury or loss does not happen to others.