If your insurance company denies coverage for cleft lip of cleft palate surgery, you need to take action. Keep in mind that insurance companies accumulate wealth by collecting premiums and refusing to pay claims. So you are in for a battle!
Most commonly, insurance companies will use wording from something that was submitted to them in a manner to make it sound as if your child’s surgery is an elective cosmetic dental procedure being done for self-esteem or appearance. However, you know that this is not why the surgery is needed. These procedures are a medically necessary in order to restore function to the body correcting a structurally abnormal congenital defect.
Another possible claim by an insurance company is that the cleft lip or palate was a pre-existing condition. However, if you insurance was arleady in effect on the date of diagnosis, there would be no basis for making this claim. And in many states, there are specific protections against these sorts of tactics used by insurance companies to deny coverage. So it can be beneficial to check with your state’s insurance commission.
In many cases the short term costs of correcting a cleft lip or palate will save money in the long run. It many just be a matter of getting the insurance company to realize that the long term costs of care may exceed the short term costs of surgery. Treatment now simply avoids what may be more expensive and complicated treatment later.
If you have not had success, consider talking with the following resources that may be available:
- Your employer’s human resources department
- The Cleft Palate Foundation
- The Cleft Lip & Palate Foundation of Smiles
- The Patient Advocate Foundation
- A lawyer, advocate, or ombudsman with experience dealing with insurance compaines
For Further Insurance Specific Resources see:
- CleftLine – A Publication of the Cleft Palate Foundation
- CleftSmile – The Cleft Lip and Palate Smiles Foundation of Smiles
- InjuryBoard – Cleft Lip & Palate Insurance Coverage Basics
Have you had problems with your health insurance company? Or did you succeed in getting coverage? Share your experience with others, ask questions, provide answers in the comment area below!
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2 Comments
MHunter
My 6 year-old son was born with a cleft lip. He was covered under my employer's health care plan. When I resigned from my position and applied for health insurance for my family, my son was denied coverage because of his cleft lip. We had continuous health insurance, yet he was denied coverage. We were advised to seek coverage under the Missouri Health Insurance Pool and he has his own policy now. In order to make our monthly premium affordable, we have a very high deductible. The fact that the insurance pool exists prevents us from having any recourse for the denial of coverage. The insurance company that denied his coverage is the company that operates the insurance pool. A scam of the highest order!
Michael Monheit
That is really awful what they did. I wonder how many other families in Missouri had this happen to them? Did you consult a lawyer in Missouri to see if there is any recourse? Have you spoken with other families who have been down the line on this issue and might have ideas for a better resolution for you?
I am very involved in a The Cleft Lip & Palate Foundation of Smiles (see: http://www.cleftsmile.org and on Facebook, http://www.facebook.com/?ref=home#!/rachel.mancuso1). I urge you to take a look at the Facebook group. There are a lot of great parents involved in that group and one of them may have ideas for you about this issue.
Finally, I am involved in litigation against prescription drug manufacturers where the mother was taking a medication during pregnancy that caused the cleft lip or palate. Drugs where we are investigating these claims are Topamax (topiramate) and Depakote. If you want further information, please contact me to discuss.
Hope all of this is helpful to you and that you find a better solution to the insurance situation.
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