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Michael Monheit
Michael Monheit
Attorney • (215) 840-6573

Cleft Palate Surgery – Insurance Coverage Basics

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I know first hand what it is like to have to advocate on behalf of your child with special needs. It is a process filled with emotions of fear, guilt, anger, but love as well. I have a daughter with special needs and during the last 20 years we have had to go to bat for her on a myriad of issues – usually involving special education, often involving habilitative services and companionship, and thank G-d not much for health coverage.

In researching this article I learned how similar my experience has been with the experiences of others. First and foremost, almost anything I have ever done on behalf of my daughter was something based on a tip I had learned from another parent. So I hope in the spirit of generosity I can pass on something I have learned, what little it has been, to help someone else. I hope that you have no use for this information, but in case you do, here it is!

First, the basics –

  • know what you want, know what you need, and know the difference
  • be persistent – never give up, and make that clear – that you will never give up
  • be informed – find people who have been down this path before you!
  • take good notes, confirm everything in writing. Keep copies of all letters.
  • be careful about what you ask for. The words that you choose to use will matter a lot

Next, the laws -

If you are not sure about your rights, consult a lawyer who can explain to you what you are entitled to. Often an initial consultation is free, and even if you have to pay for the consultation, it is money well spent if it points your in the right direction.

Your child needs surgery and the carrier has denied you… what should you do.

Read your policy…. yes, every single word of it!

  • Get a copy of any documents that your employer has on file with respect to obtaining your insurance policy.Get a copy of the proof of coverage.
  • Spend the post time on the section that discusses insurance exclusions. This is what they relied upon to deny coverage.
  • Make sure you get the denial in writing. Analyze why they denied coverage. Find the language in the insurance policy that they are relying upon. If they do not provide the denial in writing, then write them a letter asking for a written basis for the denial.

Now, you might need a lawyer at this point. The next two questions you need to answer are:

  • how long do you have to appeal?
  • what is the process for appealing?

Why will they deny?

They will probably claim one of two things. First, they will claim that your policy does not cover dental procedures. They will try to frame your request as a request for dental procedures. Back to my earlier point – the language you use matters. So never refer to this as a "DENTAL PRODECURE"!!

If they do not claim that this is a Dental Procedure, then they will probably claim that this is a "cosmetic surgery." Again, they will state that the policy does not cover cosmetic surgery. Back to my earlier point – the language you use matters. So never refer to this as a "COSMETIC"!!

What do you say in response?

First, ask to have a case worker assigned to your file. Point out to them that your child has a complex medical condition and that you need a case worker familiar with these complexities to be assigned. Put this request in writing.

Next, make clear that this is a medical condition. It is a birth defect and the procedure is medically necessary for the health of your child. A dental procedure will not repair the condition, including orthodontics and orthographic surgery.

You will probably need your doctor to help you with this, so in selecting a doctor, make sure that they understand the nature of the problem and they can not refer to this as a dental procedure or cosmetic procedure. They should avoid using those forms and avoid using those codes. They must from the get go treat your situation as a medically necessary medical procedure to treat a congenital defect medical condition. Rather than submitting this on standard forms, the doctor should write a specific letter to submit the procedures for approval. They need to outline in detail why this is medically necessary.

Back to the above basics, always put your responses in writing.

You are seeking reconstructive surgery, not cosmetic surgery. They are different. Your child’s surgery is being done to improve function, not appearance. It is being done to correct an abnormal structure caused by a congenital defect. This is very different than cosmetic surgery which is performed on normal structures to improve appearance and self-esteem.

Back to basics – Do Not Refer to this as "cosmetic" surgery. Do not say it is being done for "appearance" or for "self-esteem" of your child. It is being done to correct function and is medically necessary for biting, chewing, swallowing, breathing.

They will make you do this over and over again. Be prepared to have your story ready to go. Have it in writing so you know exactly what to tell them.

They are still denying…

Make sure you are well within the time frames for appeal. Make sure you meet all deadlines. Consider immediately hiring a lawyer.

Back to Basics…

  • know what you want, know what you need, and know the difference
  • be persistent – never give up, and make that clear – that you will never give up
  • be informed – find people who have been down this path before you!
  • take good notes, confirm everything in writing. Keep copies of all letters.
  • be careful about what you ask for. The words that you choose to use will matter a lot

Good luck. And feel free to comment below or send me a message if you can help others with this process or you think that I can help you!