I was approved for surgery late April 2010 but before having the surgery, I had to undergo some orthodontic treatment. The operation was scheduled for June 2011. My employer decided to change insurance companies in March 2011. As soon as I found out, I contacted HR. The HR person reassured me and put in writing that the new insurance plan was exactly the same as the previous one.
Once the new plan started, I found out that my surgery is specifically excluded and the new insurer will not pay for it. I got a denial letter from the new insurer. I have talked to my company’s HR person, insurance broker, and the state’s insurance ombudsman. Everyone says that I don’t have a case, because the new insurer does not cover this surgery under any circumstance.
Is there anything I can do?
Found Out Too Late
Dear Found Out Too Late,
You have the right to appeal the new insurance company’s decision. The denial letter gives you the details about how to file an appeal. This will not likely bring you anything since it is listed as an exclusion in the new contract. The new contract prevails — not the former insurer’s promise. Despite the slim odds, you may need to file the appeal before you talk to the employer about another option.
You have a very unusual option because you have a written promise from the HR department that the new insurance contract was the identical to the old one. I asked a health insurance expert what he thought of your situation. Here is what he had to say: “I would say the HR Department, and by extension the employer, just made themselves a mutual insurance company (by stating in writing that the new insurance plan was identical to the previous one). She has a great case to pursue the employer for the cost of the surgery.”
You should talk with your employer about this. They will undoubtedly want you to appeal the denial, to confirm that the new insurer will not cover the costs. Perhaps they will agree to honor their written promise to you.
Keep in mind that at best, you will get the cost of the surgery covered. You will not get any damages or other benefits. So, if you are compromising your health by further delaying the surgery, you should consider what is best for your health.
Special thanks to Alan Parks, Baystate Financial Services for his willingness to share his expertise and insight on this question.