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!