insurance company not paying!!!

melissa-5-19

insurance company not paying!!!

melissa-5-19

CA in rt-heavy family history of BC and stomach CA- neg BRAC1&2 -my insurance co is paying for rt mx- not left- anyone out there with advice on this tipic?

Somuch

I might be wrong but it is my understanding that there is a federal law stating that they have to pay for both and if you go back and have reconstruction they have to pay for that as well. Not sure how you check that out - must be something on the internet - or contact a lawyer - maybe try the American Cancer Society. There are many groups that support BC patients - there has to be one that can help you.

Good Luck, you have enough to deal with, this shouldn't have to be one more.

melissa-5-19

how come we are the only ones that "get it"?

thanks I am looking for the help you mentioned and proceding with the bilat and will fight after the fact- once to the OR is enough for me- so much so that I won't even consider recon.

thanks-love you you and you will be in my prayers

Bless

The Women's Health and Cancer Rights Act (WHCRA) contains important protections for breast cancer patients who choose breast reconstruction with a mastectomy. It was signed into law on October 21, 1998. The US Departments of Labor and Health and Human Services oversee it.  The WHCRA is a complex law. If you have questions or concerns about it, please contact the Department of Labor's toll-free number at 866-275-7922.

I found that at the ACS site www.cancer.org  by doing a yahoo search for insurance pay masectomy.  The ACS phone number is 800-228-9954

I hope that helps.  Has any one mentioned immediate reconstruction to you?  It's not right for everyone.  I'm just hoping that you've been given all possible options so that you can choose what is right for you.

God Bless

Maire67

When it comes to insurance companies be prepared to fight with everything you have and the telephone and postal mail are the weapons.  The current AARP magazine has an article about how insurance companies deny and 50 %  of patients accept that and don't fight back.  They are counting on you being sick and too tired to do this.

Write letters to your representatives in Congress,cc  the president of the insurance company, and the office of your local health company office, your governor if it's an election year.   Call your local library for names and addresses of the CEO and also telephone numbers.  Call your consumer protection office in your state.  Write to the president of the hospital and the doctor.   Having said all that all you need to do is write one letter and cc it to everyone on your list.  Nothing scares insurance companies more than cc to consumer agencies. 

If you aren't up to doing this find a friend who can do the research for you and type the letter. Send letter to CEO and representatives as registered mail to draw attention to it.

I had the fight when some insurance person decided they only needed to pay $120 for my surgeon to do a lumpectomy.   Followed a denial of the sentinal node procedure since it was done on the same day????    Work with your doctor's office too .

Good luck.. 

melissa-5-19

Bless and Marie- you are both correct- I attended a workman comp seminar (forced additional "duties as assigned") and a quote from the state level was "Deny everything, only 50% will appeal and only 25%  of those will fight to the end"- my new job is evident! Thanks for your suggestions.

May you have a physically and emotionally pain free day- Best wishes your way.

KEW

Bless--Good description of the Law, I'm writing about it right now in my Social Welfare policy class.

I have come across a section that states an insurance company only has to pay, if it pays for MX, I know your company  is paying for the one, but see if have any weeny words about paying for MX .

Here is the whole bill. Also check your state law.

As passed in H.R. 4328, the Omnibus Appropriations bill FY 99 Conference Report 105-825;
Public Law: 105-277 (10/21/98)
TITLE IX--WOMEN'S HEALTH AND CANCER RIGHTS
SEC. 901. SHORT TITLE.
This title may be cited as the ``Women's Health and Cancer Rights Act of 1998''.
SEC. 902. AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT
OF 1974.
(a) In General.--Subpart B of part 7 of subtitle B of title I of the Employee Retirement
Income Security Act of 1974 (29 U.S.C. 1185 et seq.) is amended by adding at the end the
following new section:
SEC. 713. REQUIRED COVERAGE FOR RECONSTRUCTIVE SURGERY FOLLOWING
MASTECTOMIES.
(a) In General.--A group health plan, and a health insurance issuer providing health
insurance coverage in connection with a group health plan, that provides medical and
surgical benefits with respect to a mastectomy shall provide, in a case of a participant or
beneficiary who is receiving benefits in connection with a mastectomy and who elects
breast reconstruction in connection with such mastectomy, coverage for--
(1) all stages of reconstruction of the breast on which the mastectomy has been
performed;
(2) surgery and reconstruction of the other breast to produce a symmetrical appearance;
and
(3) prostheses and physical complications all stages of mastectomy, including
lymphedemas; in a manner determined in consultation with the attending physician and the
patient. Such coverage may be subject to annual deductibles and coinsurance provisions
as may be deemed appropriate and as are consistent with those established for other
benefits under the plan or coverage. Written notice of the availability of such coverage
shall be delivered to the participant upon enrollment and annually thereafter.
(b) Notice.--A group health plan, and a health insurance issuer providing health
insurance coverage in connection with a group health plan shall provide notice to each
participant and beneficiary under such plan regarding the coverage required by this section
in accordance with regulations promulgated by the Secretary. Such notice shall be in
writing and prominently positioned in any literature or correspondence made available or
distributed by the plan or issuer and shall be transmitted--
[[Page H11161]]
(1) in the next mailing made by the plan or issuer to the participant or beneficiary;
(2) as part of any yearly informational packet sent to the participant or beneficiary; or
(3) not later than January 1, 1999; whichever is earlier.
(c) Prohibitions.--A group health plan, and a health insurance issuer offering group
health insurance coverage in connection with a group health plan, may not--
(1) deny to a patient eligibility, or continued eligibility, to enroll or to renew coverage
under the terms of the plan, solely for the purpose of avoiding the requirements of this
section; and
(2) penalize or otherwise reduce or limit the reimbursement of an attending provider, or
provide incentives (monetary or otherwise) to an attending provider, to induce such
provider to provide care to an individual participant or beneficiary in a manner inconsistent
with this section.
(d) Rule of Construction.--Nothing in this section shall be construed to prevent a group
health plan or a health insurance issuer offering group health insurance coverage from
negotiating the level and type of reimbursement with a provider for care provided in
accordance with this section.
(e) Preemption, Relation to State Laws.--
(1) In general.--Nothing in this section shall be construed to preempt any State law in
effect on the date of enactment of this section with respect to health insurance coverage
that requires coverage of at least the coverage of reconstructive breast surgery otherwise
required under this section.
(2) Erisa.--Nothing in this section shall be construed to affect or modify the provisions
of section 514 with respect to group health plans.''.
(b) Clerical Amendment.--The table of contents in section 1 of the Employee Retirement
Income Security Act of 1974 (29 U.S.C. 1001 note) is amended by inserting after the item
relating to section 712 the following new item:
Sec. 713. Required coverage reconstructive surgery following mastectomies.''.
(c) Effective Dates.--
(1) In general.--The amendments made by this section shall apply with respect to plan
years beginning on or after the date of enactment of this Act.
(2) Special rule for collective bargaining agreements.-- In the case of a group health plan
maintained pursuant to 1 or more collective bargaining agreements between employee
representatives and 1 or more employers, any plan amendment made pursuant to a
collective bargaining agreement relating to the plan which amends the plan solely to
conform to any requirement added by this section shall not be treated as a termination of
such collective bargaining agreement.
SEC. 903. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT.
nbsp; (a) Group Market.--Subpart 2 of part A of title XXVII of the Public Health Service
Act (42 U.S.C. 300gg-4 et seq.) is amended by adding at the end the following new section:
SEC. 2706. REQUIRED COVERAGE FOR RECONSTRUCTIVE SURGERY FOLLOWING
MASTECTOMIES.
The provisions of section 713 of the Employee Retirement Income Security Act of 1974
shall apply to group health plans, and health insurance issuers providing health insurance
coverage in connection with group health plans, as if included in this subpart.''.
(b) Individual Market.--Subpart 3 of part B of title XXVII of the Public Health Service
Act (42 U.S.C. 300gg-51 et seq.) is amended by adding at the end the following new section:
SEC. 2752. REQUIRED COVERAGE FOR RECONSTRUCTIVE SURGERY FOLLOWING
MASTECTOMIES.
The provisions of section 2706 shall apply to health insurance coverage offered by a
health insurance issuer in the individual market in the same manner as they apply to health
insurance coverage offered by a health insurance issuer in connection with a group health
plan in the small or large group market.''.
(c) Effective Dates.--
(1) Group plans.--
(A) In general.--The amendment made by subsection (a) shall apply to group health
plans for plan years beginning on or after the date of enactment of this Act.
(B) Special rule for collective bargaining agreements.-- In the case of a group health plan
maintained pursuant to 1 or more collective bargaining agreements between employee
representatives and 1 or more employers, any plan amendment made pursuant to a
collective bargaining agreement relating to the plan which amends the plan solely to
conform to any requirement added by the amendment made by subsection (a) shall not be
treated as a termination of such collective bargaining agreement.
(2) Individual plans.--The amendment made by subsection (b) shall apply with respect to
health insurance coverage offered, sold, issued, renewed, in effect, or operated in the
individual market on or after the date of enactment of this Act.
This Act may be cited as the Department of Labor, Health and Human Services, and
Education, and Related Agencies Appropriations Act, 1999''.
(g) For programs, projects or activities in the Department of Transportation and Related
Agencies Appropriations Act, 1999, provided as follows, to be effective as if it had been
enacted into law as the regular appropriations Act: AN ACT Making appropriations for the
Department of Transportation and related agencies for the fiscal year ending September 30,
1999, and for other purposes. 

Karen 

melissa-5-19

This is GOLD- Thank you!

melissa-5-19

Karen you wouldn't happen to know the average cost of unilaterial recon

 would you?

KEW

Melissa--I do not--this is one of the greatest issues we have with our health-care system, it depends on the hospital, doctors, region, and insurance companies involved, there is no standard cost for anything.  There was a thread called the Cost of Cancer and it was interesting until it became hijacked by someone who would not stay on topic and was verbally abusive, so it slowly died. It became pretty nasty--even I got a little snarky towards her. When some compared procedures there were thousands if not tens of thousands of dollars difference depending on where they were in the country, for the same procedure.

 I'm sorry I can't be more helpful.

Karen 

melissa-5-19

Karen that is good information also and too bad someone had to ruin the thread- the 10% rule-  am going to search insurance web sites and maybe some statistics web sites- a general goggle search mostly produced PS advertising recon and augmentation- stating that "insurance companies will pay for recon after mx."

Thanks for the good info and by the way you look so young in your photo I would never believe 48!

KEW

HI Melissa--Actually I'll be 50 in April.  I was 48 at DX.  Thank you for the compliment, but I think it was all that crazy estrogen in my body that was making me look young and feeding my cancer.

Does the hospital have a breast center?  Usually there are social workers in hospitals who should be able to give you some information on your state's laws.  Also, call your state department of insurance.  

I'm sorry you have to go through all of this.

Best--Karen 

melissa-5-19

Just another fight!-Maybe the outcome will help others in the future.

 and you still look young!

melissa-5-19

How shocking - I received and EOB from the insurance company and it appears that they MAY be paying w/o the FIGHT! I will wait and see.

KEW

Melissa--I hope so, you need to be healing not fighting.  Take care!

KarenW 

unklezwifeonty

Dear Melissa,

Heal first. Fight with insurance co later. You should be able to get the insurance co to pay up but right now if I were you I would focus on getting treated. This is no time to add stress and frustration.

melissa-5-19

You are both completely right and I really don't think about it except when the EOB came- actually I am doing well but need to build up stamina. Any suggestions? I have great range of motion, little discomfort, can sleep in any position but wear out easily. Need a nap everyday and Monday is 4 weeks- is that "normal"?