About Sara Scherer Expertise I have 13 years experience in Medical Insurance with one of the largest insurance companies in the United States. I know about plans, plan wording, and how to get around the insurance company when you need help. I worked with Medicare, Medicaid, PPO plans as well as HMO`s. I can help you get the answers you are looking for.
Experience I have 13 years experience with medical insurance. I currently work with pharmacists and their third party plans. I have worked with medical review boards and I can help you get the answers you need.
Question I am currently choosing between Cigna HMO and Cigna Open Access Plus health insurance plans. My issue is that Cigna overall (either plan) EXCLUDES from coverage REGARDLESS of clinical indications the following:
* breast reduction surgery ("Macromastia or Gynecomastia Surgeries")
* "Medical and surgical services, initial and repeat, intended for the treatment or control of obesity" (e.g. bariatric/ gastric-bypass surgery).
Can insurance companies really just exclude coverage for medically neccesary surgeries? - as Cigna writes these "services are excluded from coverage regardless of clinical indications... whether prescribed or recommended by a physician or under medical supervision."
How can I protest this so that I can have these sugeries as my doctor has recommended?
Answer These plans are purchased by your employer so that is where you want to begin. They are the only ones who can make exceptions to these exclusions. Breast reductions as well as gastric bypass are being excluded because of the cost to insurance companies. A bypass can run as much as $30,000 while a breast reduction is about $5,000. Cigna has found another way to save a few bucks for your employer and they can determine that regardless of what your doctor says, they won't pay for it.
Keep in mind that your employer decides on the coverage that they want. They can make changes but those changes only add to their premiums and considering that the average increase per year over the last 5 years has been about 12% it make medical coverage the most expensive benefit they give their employees.
