Seeking Help: My Wife’s Surgeon Denied by Insurance – How Can I Encourage Her Employer to Approve a Plan Change?
I’m reaching out for urgent 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 deemed her referral urgent. She was referred to a board-certified surgeon in Colorado, but when she contacted the surgeon’s office, they informed her that her current insurance plan, Cigna Local Plus, is not accepted.
When she sought alternative in-network specialists from Cigna, they could only provide a list of Physician Assistants and Nurse Practitioners. Unfortunately, neither PAs nor NPs are legally able to perform a lumpectomy or mastectomy independently, yet they are the only specialists covered under her current plan.
After consulting with her employer’s HR department, she learned that a major life event could potentially qualify her for a plan change. She needs to switch to Cigna’s Open Access Plus plan, which is accepted by the surgeon, but HR has not yet confirmed if her request will be approved.
I have a few questions for those experienced in HR or insurance:
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How can she effectively make her case to HR for this plan change?
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Is a serious medical diagnosis like DCIS typically considered a “major life change” for insurance purposes?
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Are there legal protections or employer obligations that could assist in expediting this process?
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Should her doctor provide a formal letter to HR, and if so, what details should it include?
We are eager to resolve this matter promptly so she can receive the necessary medical care without being hindered by insurance limitations. Any advice or strategies would be greatly appreciated. Thank you!
I’m really sorry to hear about your wife’s situation. Navigating insurance can be incredibly challenging, especially during such a stressful time. Here are some suggestions that might help you advocate effectively for her plan change:
Impact on Care: Clearly articulate how the current plan is hindering timely access to necessary care. Emphasize the risk associated with delays in treatment for a cancer diagnosis.
Major Life Event Status:
While major life events typically include things like marriage, birth of a child, or loss of other coverage, a serious medical diagnosis may fall under a grey area. HR may consider it if framed correctly. Stress that her condition requires urgent attention, which may prompt a reassessment of her case.
Legal Protections and Employer Obligations:
The Affordable Care Act (ACA) also mandates that health plans cannot deny coverage based on pre-existing conditions, but it may not directly affect plan changes outside of open enrollment.
Doctor’s Letter:
Yes, having her doctor write a formal letter can significantly bolster her case. The letter should:
Follow-Up:
Don’t hesitate to follow up with HR regularly. Keep the lines of communication open and express your urgency. It may be beneficial to escalate the matter if you feel it’s not being handled promptly.
Seek External Help:
If HR is unresponsive or unwilling to assist, consider reaching out to a healthcare advocate or an insurance broker who specializes in navigating these issues. They can give more tailored advice and might have insights into how your wife’s employer has handled similar cases in the past.
Explore Alternative Options:
Ultimately, it’s vital to act quickly given the diagnosis and the urgency of treatment. Best of luck, and I hope your wife receives the care she needs very soon.