Re: Insurance...Exclusion on Policy

[Guest guest]

What does your policy say? Typically, exclusions means that they will never

cover it. Other insurance policies that require approval are things that they

will at least reconsider if you appeal it.

>

> Hello...Cigna insurance denied coverage for my daughter's doc band based on:

>

> " per your medical benefit plan, cranial banding, cranial orthoses and similar

devices are excluded from coverage except when used post-operatively for

synostic plagiocephaly "

>

> My daughter did not need surgery, thank goodness, so no coverage for us. Has

anyone had success appealing a policy exclusion? What is the best plan of

action?

>

> Thanks so much!

>

[Guest guest]

Your only hope is to find out what laws govern your plan and see if there is one

that disallows the exclusion. Call your insurer and ask if your plan is subject

to state insurance law, and if not what law is it subject to. Then, look up the

laws and search for something about not being allowed to disallow coverage for

birth defects, deformities, etc. Otherwise, whatever the plan says goes. If you

find out which laws apply, I'll help you read through them.

The only other option I can think of is to complain to the employer the

insurance is through (human resources) about the exclusion and try to get them

to change the policy they have through the insurance company.

>

> Hello...Cigna insurance denied coverage for my daughter's doc band based on:

>

> " per your medical benefit plan, cranial banding, cranial orthoses and similar

devices are excluded from coverage except when used post-operatively for

synostic plagiocephaly "

>

> My daughter did not need surgery, thank goodness, so no coverage for us. Has

anyone had success appealing a policy exclusion? What is the best plan of

action?

>

> Thanks so much!

>

[Guest guest]

Hi,

I wanted to let you know that we just recently won our appeals that involved an

exclusion very similar to yours. We have United Healthcare though. I talked it

through with the Human Resource Department at the job we were receiving

insurance from and she said that in a previous case someone had appealed to them

to take out the exclusion and won. She said in order for me to do that too, I

would first have to appeal with the insurance twice (legal allowed limit). She

made it sound like there was a good chance we could eventually win.

So we moved forward with the DOC Band at 4 months of age and started the appeal

process right away. First one denied, because of exclusion. Second one denied,

because of exclusion. So then I made an appeal to our " Plan Administrator " at

the job that held our insurance to take out the exclusion in our policy. I sent

my previous two appeals, pictures, documents, everything and anything I thought

would help my case- and WON! The day after they received my packet appealing

the exclusion, they took it out of our policy, had the claim resubmitted and

less than two weeks later we already had a check in our hand for $2,880 our of

$3,600. My daughter was through with her band at 7 months of age and we won our

appeal and received our money back at 13 months of age. So it's been a long

process and since she was done with her band it was tempting to quit appealing

it, since it was feeling rather hopeless and because I just wanted to feel like

I could move on. But obviously very worth it in the end that I kept fighting.

So that's our story. I know some employers can't actually rewrite policies

taking exclusions out once they have been made, but others can! So I would ask

that first, then follow up with you can send a formal appeal in asking the

exclusion be taken out because of.... and send it on your documents!

Good luck!

> >

> > Hello...Cigna insurance denied coverage for my daughter's doc band based on:

> >

> > " per your medical benefit plan, cranial banding, cranial orthoses and

similar devices are excluded from coverage except when used post-operatively for

synostic plagiocephaly "

> >

> > My daughter did not need surgery, thank goodness, so no coverage for us. Has

anyone had success appealing a policy exclusion? What is the best plan of

action?

> >

> > Thanks so much!

> >

>

[Guest guest]

Thanks so much for the info, . That is such great news for you! It's

nice to hear that it's not hopeless for everyone with a policy exclusion.

I'll take your advice and start with my employer first. We'll see what

happens. Thanks again!

[Guest guest]

Cigna told us the same thing when I called them. I then talked to my husband's

HR department and they talked to Cigna and it turned out they did cover it but

it was a mistake in the policy. It is definitely worth talking to your company's

HR department!

Good luck! :-)

>

> Hello...Cigna insurance denied coverage for my daughter's doc band based on:

>

> " per your medical benefit plan, cranial banding, cranial orthoses and similar

devices are excluded from coverage except when used post-operatively for

synostic plagiocephaly "

>

> My daughter did not need surgery, thank goodness, so no coverage for us. Has

anyone had success appealing a policy exclusion? What is the best plan of

action?

>

> Thanks so much!

>

[Guest guest]

We recently won our insurance appeal for my son's helmet and our insurance

policy has a similar exclusion (something to the effect that cranial orthoses

are not considered medically necessary because there is no evidence in the peer

reviewed literature to support that they are an effective treatment for

plagio/brachy). The process was long and frustrating but worth it for us in the

end. Good luck!

>

> Hello...Cigna insurance denied coverage for my daughter's doc band based on:

>

> " per your medical benefit plan, cranial banding, cranial orthoses and similar

devices are excluded from coverage except when used post-operatively for

synostic plagiocephaly "

>

> My daughter did not need surgery, thank goodness, so no coverage for us. Has

anyone had success appealing a policy exclusion? What is the best plan of

action?

>

> Thanks so much!

>