Help Needed: My Wife’s Cancer Surgery Referral Denied by Insurance – How Can We Get Her Employer to Approve a Plan Change?
I urgently need advice from HR professionals, insurance brokers, or anyone familiar with employer-sponsored health plans.
My wife has recently been diagnosed with grade 3 ductal carcinoma in situ (DCIS) in her left breast. Her doctor marked her referral as urgent and recommended a board-certified surgeon in Colorado for her treatment. Unfortunately, when she reached out to the surgeon’s office, they informed her that her current plan, Cigna Local Plus, is not accepted.
When she contacted Cigna for a list of in-network specialists, they provided only Physician Assistants (PAs) and Nurse Practitioners (NPs). However, neither PAs nor NPs can perform a lumpectomy or mastectomy independently, yet these are the only “specialists” covered under her current plan.
After speaking with her employer’s HR department, they indicated that a significant life event might qualify her for a plan change. We need to switch to Cigna’s Open Access Plus plan, which the surgeon does accept, but HR has not yet confirmed if they will allow this request.
I have a few questions for HR or insurance experts:
- How can she effectively present her case to HR for plan change approval?
- Is a serious medical diagnosis like DCIS considered a “major life change” for insurance eligibility?
- Are there any legal protections or employer obligations that could support our case?
- Should her doctor write a formal letter to HR, and if so, what key points should it cover?
We are eager to resolve this matter quickly so she can receive the necessary care without any further delays due to insurance issues. Any insights or strategies would be greatly appreciated. Thank you!
I’m really sorry to hear about your wife’s situation. Navigating insurance issues during such a challenging time can be incredibly frustrating. Here are some suggestions based on your questions:
Argument to HR: When approaching HR, it’s crucial to present a clear and documented case. Highlight the urgency of your wife’s diagnosis, mentioning that DCIS is a serious condition that requires timely intervention. Emphasize that the current insurance plan limits her access to appropriate care, resulting in a potential delay in critical treatment. It may also be helpful to provide specific timelines for treatment and potential impacts on her health if delays occur.
Major Life Change Qualification: A serious medical diagnosis often qualifies as a major life event, particularly when it significantly impacts a person’s health and requires new medical interventions. While the specifics can vary by employer and insurance plan, you can argue that this diagnosis necessitates a change in coverage to ensure she receives the necessary surgical care.
Legal Protections and Employer Obligations: The Affordable Care Act (ACA) requires group health plans to provide certain protections. While these laws typically won’t force an employer to allow a plan change outside of open enrollment, many employers value the health of their employees and may have discretionary policies to accommodate urgent medical needs. Also, if there’s a particularly defined ‘urgent care’ provision within your wife’s company’s health plan, that could also play in your favor.
Doctor’s Letter: Yes, having her doctor write a formal letter can be very beneficial. The letter should clearly state your wife’s diagnosis, the recommended treatment, the necessity for seeing a board-certified surgeon, and the urgency involved. It should also articulate that the current insurance plan will not provide adequate care and emphasize that transitioning to a different plan is essential for her health and wellbeing.
Overall, persistence is key. Follow up regularly with HR, and ensure that you’re communicating the urgency of the situation clearly. It may also be helpful to explore any appeals process that Cigna might have regarding specialists. I hope you find a positive resolution soon, and your wife receives the care she needs.