My Wife Was Denied a Surgeon Due to Insurance. How Can I Get Her Employer to Approve a Plan Change?

by IFadmin

Seeking Guidance: My Wife’s Urgent Need for a Surgeon Denied by Insurance—How Can We Secure a Plan Change?

I urgently need advice from HR professionals, insurance brokers, or anyone knowledgeable about 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 marked her referral as urgent. She was referred to a board-certified surgeon in Colorado, but when she contacted the surgeon’s office, they informed her that they do not accept her current insurance plan, Cigna Local Plus.

When she reached out to Cigna for in-network specialists, the only referrals they provided were for Physician Assistants (PAs) and Nurse Practitioners (NPs). Unfortunately, these professionals cannot independently perform the necessary procedures, such as a lumpectomy or mastectomy—yet they are the only specialists available under her current plan.

She spoke with her employer’s HR department, and they mentioned that a major life event could potentially qualify her for a change in insurance plan. She needs to be switched to Cigna’s Open Access Plus plan, which the surgeon would accept, but HR has not yet confirmed whether they will approve this request.

Here’s what I need to know:

  1. What arguments might she use to convince HR to approve her plan change?

  2. Is a serious medical diagnosis like DCIS typically recognized as a “major life change” for the purposes of insurance exceptions?

  3. Are there any legal protections or employer obligations that could facilitate this process?

  4. Should her doctor write a formal letter to HR, and if so, what specifics should it include?

We are eager to resolve this situation so that she can receive the necessary care without further delays due to insurance limitations. Any insight or strategies would be greatly appreciated. Thank you!

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One thought on “My Wife Was Denied a Surgeon Due to Insurance. How Can I Get Her Employer to Approve a Plan Change?”

  1. I’m really sorry to hear about your wife’s diagnosis, and the challenges you’re facing with her insurance coverage. Navigating these situations can be incredibly stressful. Here are some suggestions that might help in your discussions with HR and the insurance company:

    1. Arguing her Case to HR:
    2. Document Everything: Compile all relevant medical records, referrals, and communications with both the surgeon and Cigna. This will help demonstrate the urgency and necessity of the procedure.
    3. Highlight Urgency: Emphasize the urgent nature of her medical condition. Stress that timely treatment is critical in cases of breast cancer to improve outcomes.

    4. Personal Statement: Consider having your wife write a personal statement detailing her situation, why she needs to switch plans, and how the current plan limits her access to necessary care.

    5. Qualifying as a Major Life Change:

    6. While major life changes typically include events like marriage, divorce, or having a baby, a serious diagnosis can be considered under the right circumstances. It’s vital to clearly articulate how her condition affects her coverage needs and care options, emphasizing the urgency.

    7. Present evidence that undergoing surgery is not only crucial but also time-sensitive due to the nature of her diagnosis.

    8. Legal Protections and Employer Obligations:

    9. Employers are usually obligated to comply with the provisions of the Affordable Care Act (ACA). This includes considerations for timely access to care.
    10. Look into your state regulations regarding insurance and employer obligations; some states have specific laws mandating timely care access, especially in serious health situations.

    11. Inquire whether your employer is subject to any federal laws, such as the Employee Retirement Income Security Act (ERISA), which may influence their decision.

    12. Doctor’s Formal Letter to HR:

    13. Yes, having her doctor write a formal letter can be beneficial. This letter should include:
      • A clear diagnosis and the medical necessity for surgery.
      • An urgent request for timely approval to switch insurance plans to ensure appropriate care.
      • A statement about the qualifications required for performing the surgery (such as the need for a board-certified surgeon) and why the current plan is insufficient.

    Lastly, don’t hesitate to reach out to a patient advocacy group or consider working with a health insurance advocate who can help navigate these insurance complexities. It may also be worth exploring options for an expedited review or appealing to higher levels of HR if necessary.

    Wishing you both the best in securing the care your wife needs.

    Reply

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