Insurance won't cover

[MThompson3@aol.com]

I am 23 years old and I was born with a cleft lip and palate. I never had a pharyngeal flap surgery when I was young. My speech is far from normal. My insurance company refuses to cover the surgery saying "it is cosmetic." Is there anything I can do? Help!

[Carol]

Fight it! I am 32 years old and have a cleft lip and palate. I've had many surgeries, some of them were as an adult. I was not covered under my parents insurance anymore. I had my own insurance through work. Throughout my adult working life I've had coverage with a couple of different insurance companies through my place of work. One was great, the other was not. The one that was not great tried to deny coverage for the surgery--stating that it was cosmetic. I fought it. My case ended up going to an independent group outside the insurance company. What the independent group decided is what the insurance company HAD to follow. The independent group determined that it should be covered. End result: the insurance company HAD to pay for it. This was a number of years ago when this happened (about 8 years ago), but you don't have to take no for an answer. It is NOT purely cosmetic. Ask the insurance company if there are any further steps you can take within their organization to take it to a higher level. Or talk to your human resources person at the company where you work (mine helped me). Also, have your doctor(s) write letters to your insurance company. Mine did for me and they were happy to do so. It may take a while to get it resolved--possibly months of just waiting--but it is worth it if you get the coverage you want and should have had in the first place! Good luck! Hope it works out for you.

[Anonymous]

the term you want to use with your insurance co is 'reconstructive' surgery .... its purpose is to restore 'function'. Your surgery will restore function of your soft palate or your throat wall or whatever it is they are correcting. But it is reconstruction, and not merely cosmetic. If you call 1-800-24-cleft you can ask for some information from the American cleft palate Association. Thisis the oversee group that helps to set policy about this sort of thing. Good luck and don't take no for an answer. Pat

[Renee (tennesseevol]

My 5 yr old daughter was born with cleft lip and palate. June 4th made her third surgery since birth. Her first came at 2 mos old with the lip, 6 mos old was the appliance application to her palate, and the most recent was a bone graph for her gum, the appliance removed and the palate stitched. She has one more in December to repair her nose. Through the first 2 surgeries we never had a problem with insurance. This last one however we had some horrible problems with primary care physicians refusing letters of referral. When Kristyn was born we lived in Tennessee so her surgery was performed by Dr. Steven J. Smith of the Knoxville Craniofacial Clinic. He's wonderful by the way. We moved to SC and the pediatricians her wanted to send her to Charleston to a Dr. to finish up her surgeries. I refused, my theory is stick with the DR. who began the process. This is something she has to live with for the rest of her life. I now travel 300 miles for scheduled Drs visits with him as well as surgery. He's worth it. My point is you need to find out if your company is self insured. If so contact the benefits office. My husband works for Cracker Barrel and they are self insured so they overroad everything the insurance company said. We had the surgeries approved with out referral at 90%. It's worth investigating. I know what kind of headache you are having with this. It's a shame that doctors in our younger days were not up on this sort of thing that you have had to wait all your life to have something done. Now most insurances consider it a preexisting condition and they won't cover it. I hope everything works out for you. Please keep me posted. I don't know where you live, but if you don't mind a long distance call, you can call Dr. Smith's office to see if they know where you might be able to receive some funding. I'm not for sure if there is such a thing. I mean if they have free clinics for other medical problems then why shouldn't there be for this issue. I don't understand the insurance companies today, if this will benefit you and your well being (speech) why can't it be covered. It's worth calling Dr. Smith and asking his opinion. Like I said, he's great... His number is 865-541-3700 he's located at Ft. Sanders Hospital Medical Building in Knoxville Tennessee. Good Luck.... Renee

[Lori Woodward]

I have had some of those exact problems with our insurance company. My 6 year old son is going to have the flap done in 3 months. FIGHT THE INSURANCE COMPANY. I have called them every day, ask to talk to supervisors. Get a written statement from a speech path. Show the insurance company some documentation. Over all FIGHT!! They just like to see how easily we (the patient) will back down!