How can I get insurance to pay for a breast reduction when it's excluded?

Question

I have group health insurance with BCBS of Louisiana and listed in my booklet it says breast reductions or anything to do with them are excluded from coverage "regardless of medical necessity". This is a surgery I need as a medical necessity due to back/shoulder/neck pain, tingly hands and fingers, sore b*****s, etc....I've already been evaluated by several surgeons and chiropractors who have all said a breast reduction is the only thing that will solve my pain issues. Is there any way around this exclusion or any other way of getting it done besides paying for it out of pocket? I am aware of health care loans but I do not think I'd qualify. I'm looking for insurance related solutions. If it helps any, we live in Alabama but our insurance is BCBS of LA.

Answer 1

You have to either get on a different insurance plan or self-pay.

Answer 2

If your policy says that breast reductions are excluded "regardless of medical necessity," then there is nothing in the world that you can do to get the surgery covered.

(Please feel free to confirm that with the Department of Insurance in your state - they will tell you the same thing.)

Your policy is a contract for the services exactly as spelled out in the policy - no more, no less.  And there are no exceptions to those kinds of exclusions...if they did it for you, they'd have to do it for everyone with the same type of policy as you.

(When your employer negotiated or purchased a policy that excluded such a service "regardless of medical necessity," their premiums were adjusted.  So, none of the premiums that either you or your employer are paying go towards potential coverage of that service.)

If you feel that you really need to get the surgery done, you have 2 options:

1)  Find a way to pay for it yourself

2)  Get a different job that comes with a health plan that don't exclude breast reduction surgery.  (Keeping in mind that virtually any insurance company would require prior approval...after you got the new job, you wouldn't be able to just have the surgery immediately.  You'd have to go through all the appropriate steps.)

I'll tell you that its somewhat rare (in my observation) for a benefit plan to exclude coverage for breast reductions regardless of medical necessity.  But, its not illegal - anything except state-mandated benefits can be excluded on a policy.  Many employer groups are starting to get creative with exclusions to help keep premiums down, while still being able to provide basic benefits to their employees.  So, if you decide to go the "get another job route," the odds of your next plan providing coverage for a breast reduction would probably be fairly good.  (Assuming that you met all the medically necessary criteria, got the prior approvals, weren't subject to a pre-existing condition clause, etc.)

Answer 3

There's no way around it.  You either have to move to another state, and get a new policy, or pay for this out of pocket.  

That BCBS of LA, that covers you in AL, is actually an AL policy, not a LA policy.

Answer 4

If you can get a doctor statement that it is a medical necessity you can get it covered. Real necessity.

You may also apply for a medical insurance card that will allow you to get whatever medical treatment you want-even vet medical.

http://www.carecredit.com

Answer 5

The terms of your policy are very clear.  They won't pay for it 'regardless of medical necessity'.  In other words, it is totally excluded, no matter the reason.  Most insurers will exclude breast reduction surgery from coverage due to common fraud.  It's VERY easy to get a physician to state that it is a medical necessity because of pain, regardless of whether or not the patient actually HAS pain.  That's why it is excluded

Answer 6

I would call customer service,   at bcbs  and ask them...  there should be a way around it...  cause mine will be covered (I've checked)  and it's the same insurance coverage...

Answer 7

Since it says regardless of medical necessity I doubt you can without a lawyer and that means you would just be out thousands...kind of counter productive.

Let me end by saying....please don't do it.

Answer 8

call the customer service of the insurance comapny. Check out the details attached to your policy. Then you may be able to get some answers.

http://www.rghins.com/

Answer 9

If breast reduction surgery is excluded in the policy, there's not a lawyer in the world that can make them pay.

Insurance policies say what they will pay for, then the exclusions sections say what they won't pay for.