Hi Mary Grace,

Unfortunately, I am a licensed insurance agent in Ohio and have been in insurance in various capacities over the past 30 years.  It really depends on a lot of factors as to whether it will be easy or difficult to get a surgery approved.  I would need to have more information to lead you in the right direction.  Here are some things I would need to know:

What type of insurance does the child have?  Is it private insurance (HMO, PPO etc) or Medicare or Medicaid? 

What type of surgery does this child need and for what?  The reason I ask this is because the surgery may be considered experimental and/or investigative. The fact that you mentioned the surgery is rare may be the reason the surgery has been denied. But I would not give up.  Especially if nothing else has worked and it is the only known surgery available to help this child.

What was the reason for the insurance denying or not approving the surgery to be performed by Dr. Scott?

I do know, from past experience, if you contact your congressman, he/she has to respond.  Many will assign a staff member  to assist  you.  If the child is considered disabled, you can also call the Civil Rights Commission in your state and they may also get involved. It is certainly worth a try.

If you can get me the answers to the above questions, I will be more than happy to assist this family in anyway I can to help get this child any needed surgery. If you would prefer, you can PM me.

Hugs,

Lore

Hi Greg,

It depends on the type of insurance you have.  Are you in a closed network HMO?  If so, you probably don't have an out-of-network benefit.  If you have an out-of-network benefit like a PPO then there should be no problem.  It just means you will have to pay more money out-of-your pocket.  It sounds to me like you might be in a closed network HMO.  Do you know if that is correct?

Brain bypass surgery can be considered investigative/experimental depending on your insurance and their exclusions.  However, I would fight it with the most recent statistics.  These surgeries went by the wayside in the 1980's because they were considered not to work.  What you have to keep in mind, is in the 80's they were doing these surgeries on elderly people only, for the most part.  Today, things have changed with perfecting these surgeries and there is recent studies that show they can significantly reduce stroke.

Let me know what type of insurance you have and I can help you from there.

Hopefully, we'll talk soon.

Hugs,

Lore

Hi Greg,

Gosh, I hope your not ick of hearing from me since I've also posted on your other topic.

I'm glad to hear you have an out-of-network option. Yes, you could be responsible for anything above the UCR.  However, most doctors and hospitals will negotiate and accept UCR payment.  But I would get it in writing.  Don't take their word for it.

If your company is self-insured, that means they accept all the risk.  There may or not be stop loss insurance but that really has nothing to do with you.  When a company is self-insured they call the shots.  It's their money.  They may have agreed to whatever CIGNA decides simply because that is why they choose them as an administrator because your company is not in the business of paying claims or making medical decisions.

Most insurance companies have what is called "centers of excellence".  Meaning depending on the type of disease/treatment dictates where you go for the specialized treatment you need. Also, there is an appeal process for denials.  It is probably first with CIGNA and if you disagree with their decision, your company may also have an appeal procedure in place since they are self-insured.

I hope this is of some help to you.  Let me know if you get denied being you have an out-of-network benefit. I would have to believe, at that point, the procedure is considered experimental/investigative by CIGNA and may be an exclusion of your contract.

Keep me posted.

Hugs,

Lore

Hi Irene,

Glad to hear from you since I know you went back to work. Kevin and I having been thinking about you and how you are doing now that you've had to go back to the ole grind.

Gosh, I hope you aren't having problems with insurance!

I don't believe anyone who is dealing with a disease or illness should have to put up with insurance... period. They have made it so difficult for people to simply get proper treatment and deal with getting better. Makes my blood boil.  I'm actually embarrassed to say I'm in insurance. However, what's nice about it is I can take the problems other face in getting treatment and use those scenarios to determine if the product is going to serve the person well or not before purchasing.

Take care and keep us posted on how you are getting along.

Hugs,

Lore and Kevin