My Wife’s Insurance Denied Her a Surgeon – How Can I Get Her Employer to Approve a Plan Change?
I urgently need advice from HR professionals, insurance brokers, or anyone experienced with employer-sponsored health plans.
My wife has been diagnosed with grade 3 ductal carcinoma in situ (DCIS) in her left breast, and her doctor has deemed her case urgent. Despite her primary care physician referring her to a board-certified surgeon in Colorado, her attempt to schedule an appointment was denied because her current plan, Cigna Local Plus, isn’t accepted by the surgeon.
When she reached out to Cigna for a list of in-network specialists, they provided only Physician Assistants (PAs) and Nurse Practitioners (NPs). Unfortunately, PAs and NPs are not authorized to perform surgical procedures like lumpectomies or mastectomies, leaving my wife with no viable options under her current plan.
After consulting with her employer’s HR department, they mentioned that a significant life event might allow for a plan change. We’re looking to switch to Cigna’s Open Access Plus plan, which the surgeon accepts, but HR has yet to confirm if this request will be approved.
I have a few questions for HR/Insurance Experts:
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What arguments can she present to HR to strengthen her case for a plan change?
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Is a diagnosis of DCIS considered a “major life event” that would typically allow for insurance exceptions?
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Are there any legal protections or employer responsibilities that might assist in expediting this process?
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Should her doctor submit a formal letter to HR? If so, what key points should it include?
We’re eager to resolve this issue so she can receive the necessary care without further delays due to insurance limitations. Any insights or strategies would be greatly appreciated. Thank you!
I’m really sorry to hear about your wife’s situation. It sounds incredibly stressful, and I hope I can provide some guidance to help you navigate the insurance challenges. Here are some thoughts on your questions:
The limitations of the current plan are compromising her access to necessary care.
It may help to bring in documentation from her doctor detailing the urgency of her condition and the necessity to see a specific surgeon.
Major Life Changes: While the definition of “major life change” can vary by employer and insurance plan, a serious medical diagnosis often qualifies. Stress the critical nature of her condition to HR, referring to it as potentially life-threatening if not treated properly. You may also want to check with your state’s insurance department for further guidance regarding qualifying life events.
Legal Protections and Employer Obligations: Employers typically must adhere to the terms of their health plans, but they also have an obligation to provide a safe and healthy workplace. The Affordable Care Act (ACA) may offer protections regarding access to necessary medical care. You might want to get in touch with a medical advocacy group or a healthcare attorney for insight into any legal protections available in your state regarding insurance plan changes.
Doctor’s Letter: Yes, having her physician write a formal letter can significantly bolster your case. This letter should:
Finally, while you work through this process, consider reaching out to patient advocacy groups or local cancer support organizations—they may provide additional resources or guidance as you navigate the insurance maze. I truly hope your wife receives the care she needs as soon as possible.