Re: Hello - I've just joined your group

[Guest guest]

Hi there Diane

I can't believe they're trying to deny based on pre-existing. I hate

insurance companies

There are ways around the pre-existing clause, so if the only reason

your insurance company won't pay for the surgery is because they're

considering it a pre-existing condition, I have a few questions for

you:

How long have you had this particular insurance company? Is it a

group plan or did you buy it individually? The law I'm thinking of

only applies to group plans :/

Prior to this company, were you insured with another?

Was there a lapse of coverage between the two? (waiting periods

before being eligible for coverage are not counted as lapses)

Where do you live? (US or otherwise)

There's a ton of information in this link about the HIPAA law, pre-

existing conditions, coverage, etc.

I hope this helps

> Hello, I just joined your group, but I've been " living " with an

> underbite for thirty-plus years. I would LOVE to have Orthognathic

> Surgery, but my insurance won't pay for it, as it is considered a

pre-

> existing condition. As far as I'm concerned, it's a latent

congenital

> defect in need of correction. I received mine from my parents -

got

> my mandible from my Mom and my maxilla from my Dad. I'm about to

> undergo an extraction of one of my teeth due to an abscess (it's

> tooth #K) - the surgery is next Friday. Then, I'll be waiting for

two

> months for the extraction site to heal so that I can have an

implant

> installed. I've found a wonderful Oral and Maxillofacial Surgeon

(the

> one who is doing my implant) who would also LUV to perform

Bilateral

> Mandibular Osteotomies with some Maxillary Advancement on me as

well,

> so we'll see. At this stage of my life, I feel that I'm finally

ready

> to undergo all this and I'm enthusiastic about what the future may

> have in store for me. This will be the third time in the last

twenty-

> five years that I've considered this type of surgery; the previous

> two times were for more cosmetic reasons. Now, it's all about

> function. I've noticed big changes in mastication and speech;

chewing

> seems to take longer and if pressed for time I have noticed I

swallow

> partially chewed food: that can't be good for my GI tract. My

speech

> is becoming harder for others to understand; I guess I'm mumbling

> more and forced to repeat what I am saying.// Well, thank you for

> letting me tell my story. Would love to hear from any of you about

> this, especially how to pay for all of this. /// Diane

[Guest guest]

Good luck to you, Diane!

I think you're on the right track. And a good, interested surgeon is

your best ally in persuading an insurance company to live up to its

obligations.

My lower advancement was done exactly on the basis you say -- repair

of a congenital skeletal deformity, a hypoplasia (or hyperplasia, I

forget which) of the lower jaw. And the company paid for it.

Other possibilities: Use a dental school. Some people have been very

happy going that route, and have received lower prices, on both ortho

and surgery.

Some people have undertaken home mortgages, and some have negotiated

with both the surgeon and the hospital for financing and lower fees.

Good wishes to you. Hope you can come up with a solution.

Of course, in Canada it's covered under the health plan, just in case

of you're thinking of becoming one of the many emigrants from the U.

S. to Canada, although I think the Canadians have had to make it a

bit tougher than it used to be to become a Canadian. (Maybe in the

U.K., too, although I know no details of either.)

Cammie

> Hello, I just joined your group, but I've been " living " with an

> underbite for thirty-plus years. I would LOVE to have Orthognathic

> Surgery, but my insurance won't pay for it, as it is considered a

pre-

> existing condition. As far as I'm concerned, it's a latent

congenital

> defect in need of correction. I received mine from my parents -

got

> my mandible from my Mom and my maxilla from my Dad. I'm about to

> undergo an extraction of one of my teeth due to an abscess (it's

> tooth #K) - the surgery is next Friday. Then, I'll be waiting for

two

> months for the extraction site to heal so that I can have an

implant

> installed. I've found a wonderful Oral and Maxillofacial Surgeon

(the

> one who is doing my implant) who would also LUV to perform

Bilateral

> Mandibular Osteotomies with some Maxillary Advancement on me as

well,

> so we'll see. At this stage of my life, I feel that I'm finally

ready

> to undergo all this and I'm enthusiastic about what the future may

> have in store for me. This will be the third time in the last

twenty-

> five years that I've considered this type of surgery; the previous

> two times were for more cosmetic reasons. Now, it's all about

> function. I've noticed big changes in mastication and speech;

chewing

> seems to take longer and if pressed for time I have noticed I

swallow

> partially chewed food: that can't be good for my GI tract. My

speech

> is becoming harder for others to understand; I guess I'm mumbling

> more and forced to repeat what I am saying.// Well, thank you for

> letting me tell my story. Would love to hear from any of you about

> this, especially how to pay for all of this. /// Diane

[Guest guest]

I don't think that's entirely true. I believe MSP covers the ortho

and surgery if you're under 20 years old and fall under specific

cases. I'm 30 years old and not a penny of my ortho and surgery were

covered, except 80% of x-rays and most of the hospital fees. Both my

OD and OS told me I basically had no chance with MSP or any insurance

carrier (as with most of their patients), despite having severe life-

long problems masticating, etc. I work at a large high-tech company

with a decent benefits plan, but only $2,000 of braces are covered for

the owner's CHILDREN (not even myself). Not to mention that $2,000

doesn't really help much. Some plans won't even cover that if surgery

is involved, such as with the last company I worked for.

Declining coverage seems to be the growing norm in Canada. Just 5

years ago I could have had my teeth cleaned every single day for free

(covered by my company benefits). Now I'm lucky if I can find a

company that will pay 100% of a cleaning/check-up (some won't pay if

there's less than 6 months in between). Then there's the ever

decreasing yearly cap for each code category.

On the other hand, my surgery was apparently still much cheaper than

what it would have cost in the US. So despite my complaints about the

dwindling benefits here and my new debts, I'm still glad to have been

in Canada for this. But it wasn't covered per say and I do have one

hell of a bill to pay over the next few years.

> Of course, in Canada it's covered under the health plan, just in

case

> of you're thinking of becoming one of the many emigrants from the U.

> S. to Canada, although I think the Canadians have had to make it a

> bit tougher than it used to be to become a Canadian. (Maybe in the

> U.K., too, although I know no details of either.)

>

> Cammie

>

[Guest guest]

Thank you for replying. First of all, I live in Idaho, have been here

since 1980; I have worked for the largest hospital system in the

state for 25 years; I have a group insurance plan with Blue Cross.

Also, my plan lists the following under " Exclusions for Dental

Benefits under the Plan: - For orthognathic surgery, including, but

not limited to, osteotomy,ostectomy,and other services or supplies to

augment or reduce the upper or lower jaw. " Another exclusion listed -

" Not Medically Necessary " . Denying due to a pre-existing condition

was the reason the insurance company gave when I was last worked up

by an Oral Surgeon to have the surgery, back in 1998. (That surgeon

was a real jerk - I'm glad I didn't let him do the surgery). Anyway,

this time I've found the right OMS for the job. It's hard to believe

that a HOSPITAL can't develop better health benefits for its

employees. They should offer any surgery to its employees for the

correction of congenital skeletal defects. I think this is case of

Discrimination - plain and simple. This makes me so-o mad I could

scream! (I wonder if I will have to consult an attorney and sue my

employer.) / Well, thanks for letting me get this off my chest. Does

anyone have any suggestions? // Diane

> > Hello, I just joined your group, but I've been " living " with an

> > underbite for thirty-plus years. I would LOVE to have

Orthognathic

> > Surgery, but my insurance won't pay for it, as it is considered a

> pre-

> > existing condition. As far as I'm concerned, it's a latent

> congenital

> > defect in need of correction. I received mine from my parents -

> got

> > my mandible from my Mom and my maxilla from my Dad. I'm about to

> > undergo an extraction of one of my teeth due to an abscess (it's

> > tooth #K) - the surgery is next Friday. Then, I'll be waiting for

> two

> > months for the extraction site to heal so that I can have an

> implant

> > installed. I've found a wonderful Oral and Maxillofacial Surgeon

> (the

> > one who is doing my implant) who would also LUV to perform

> Bilateral

> > Mandibular Osteotomies with some Maxillary Advancement on me as

> well,

> > so we'll see. At this stage of my life, I feel that I'm finally

> ready

> > to undergo all this and I'm enthusiastic about what the future

may

> > have in store for me. This will be the third time in the last

> twenty-

> > five years that I've considered this type of surgery; the

previous

> > two times were for more cosmetic reasons. Now, it's all about

> > function. I've noticed big changes in mastication and speech;

> chewing

> > seems to take longer and if pressed for time I have noticed I

> swallow

> > partially chewed food: that can't be good for my GI tract. My

> speech

> > is becoming harder for others to understand; I guess I'm mumbling

> > more and forced to repeat what I am saying.// Well, thank you for

> > letting me tell my story. Would love to hear from any of you

about

> > this, especially how to pay for all of this. /// Diane

[Guest guest]

Hello again, Diane.

It may well be that you will need a lawyer. And you should know that

at least one patient who is a lawyer fought hard, went through

multiple appeals in another state, and did not win.

Some states require that any insurance company that covers one

repair of a skeletal anomaly must cover others: If they would pay

for repair of a leg that's shorter than the other, or a clubbed

foot, they must also pay for repair of a jaw that's too short.

I can't tell you why I have this prejudice (and that's what it is,

pure and simple) but I'd be surprised to learn that Idaho has such a

law. My own Alabama does not: The insurance interests, which own a

lot of members of the state legislature, beat such a bill back some

years ago, my surgeon told me.

You can also appeal to the state board that regulates insurance

companies.

But your best bet is to talk with your surgeon about what he or she

has found that does/does not work. And ask for the surgeon's help,

and that of the insurance specialist in the office, and follow the

advice, best you can.

Also, keep careful records. This means recording the dates of any

conversations, the name and position of the person with the

insurance company with whom you speak, and what is said. (Record

them if you can, and if it is legal in your state.) The more detail

you can present to whatever agency/court/regulatory board, the

better.

Get everything you can in writing. (Insurance companies have also

been known to give written approval, and then rescind it a day or

two before, or even after, surgery.)

And send any submissions to the company by some form of mail that

gives you a receipt, preferably with a signature from an agent of

the insurance company. You would not believe the run-arounds people

have had from companies that have " lost " submissions (including

molds, x-rays, photos, drawings, etc.,) multiple times, although

there were recorded, signed receipts.

It can be just amazing, almost as though some firms act as though

the more hurdles they set up, the more likely you are to give up.

And then they win.

In fairness, I should also say that my company gave approval on the

first submission, which my surgeon's office sent. They were quick to

approve, renewed their approval, and paid almost everything. So

there are some good guys in the business, too. I am most fortunate

in that the company for which I work takes good care of its

employees, as well, and is generous in the insurance policies it

provides. I wish all had such benefits.

And I agree with your assessment about the hospital. But I found

that one of my e-mail correspondents who works for a hospital nearby

was severely restricted as to the surgeons she could use, or even

which branch of the hospital for which she worked. It's amazing.

C.

> Thank you for replying. First of all, I live in Idaho, have been

here

> since 1980; I have worked for the largest hospital system in the

> state for 25 years; I have a group insurance plan with Blue Cross.

> Also, my plan lists the following under " Exclusions for Dental

> Benefits under the Plan: - For orthognathic surgery, including,

but

> not limited to, osteotomy,ostectomy,and other services or supplies

to

> augment or reduce the upper or lower jaw. " Another exclusion

listed -

> " Not Medically Necessary " . Denying due to a pre-existing

condition

> was the reason the insurance company gave when I was last worked

up

> by an Oral Surgeon to have the surgery, back in 1998. (That

surgeon

> was a real jerk - I'm glad I didn't let him do the surgery).

Anyway,

> this time I've found the right OMS for the job. It's hard to

believe

> that a HOSPITAL can't develop better health benefits for its

> employees. They should offer any surgery to its employees for the

> correction of congenital skeletal defects. I think this is case of

> Discrimination - plain and simple. This makes me so-o mad I could

> scream! (I wonder if I will have to consult an attorney and sue my

> employer.) / Well, thanks for letting me get this off my chest.

Does

[Guest guest]

Hello, Cammie - I'm sorry about my last post - I was just so angry

and frustrated at my stupid insurance company. I talked with my

massage therapist who told me she worked for an insurance broker when

she lived in San Diego and it was rather common for people to

purchase " riders " on their policies for special reasons, such as a

Neonatal rider for a high-risk pregnancy. She suggested that I shop

around for a broker who is willing to do one for me - maybe one that

can include Orthodontia as well, as my policy will only pay for

$1000. I will definitely talk to my surgeon about all this though.

Thank you for writing back to me and for your support. / Diane

> > Thank you for replying. First of all, I live in Idaho, have been

> here

> > since 1980; I have worked for the largest hospital system in the

> > state for 25 years; I have a group insurance plan with Blue

Cross.

> > Also, my plan lists the following under " Exclusions for Dental

> > Benefits under the Plan: - For orthognathic surgery, including,

> but

> > not limited to, osteotomy,ostectomy,and other services or

supplies

> to

> > augment or reduce the upper or lower jaw. " Another exclusion

> listed -

> > " Not Medically Necessary " . Denying due to a pre-existing

> condition

> > was the reason the insurance company gave when I was last worked

> up

> > by an Oral Surgeon to have the surgery, back in 1998. (That

> surgeon

> > was a real jerk - I'm glad I didn't let him do the surgery).

> Anyway,

> > this time I've found the right OMS for the job. It's hard to

> believe

> > that a HOSPITAL can't develop better health benefits for its

> > employees. They should offer any surgery to its employees for the

> > correction of congenital skeletal defects. I think this is case

of

> > Discrimination - plain and simple. This makes me so-o mad I could

> > scream! (I wonder if I will have to consult an attorney and sue

my

> > employer.) / Well, thanks for letting me get this off my chest.

> Does