Help With Cleft Lip and the Insurance Company
When your child is born with a cleft lip the last thing that you want to worry about is money. Your child's health and emotional well-being are at the top of your list. But, like it or not, paying for the surgeries is a factor. You'll be relieved to know that in most states, medical insurance does cover cleft lip and cleft palate surgeries. It is listed as a medically necessary reconstructive procedure to restore function.
While most insurance companies will cover the majority of surgical costs, leaving the insured some small financial responsibility, others may question the medical necessity. Why does this happen? It could be because the agent handling your case doesn't have a medical background. If you feel this is the case ask to deal with the case manager, or at least someone who is fully informed about cleft lip.
The insurance carrier may also see the cleft lip condition as a cosmetic surgery and deny coverage. You will need to emphasize the fact that a cleft lip does interfere with health and nutrition. Your understanding of the symptoms, and being able to verbalize it to the insurance agent, may be enough to make them understand the importance of cleft lip surgery.
Some insurance providers may consider the cleft lip or cleft palate surgery a dental procedure and feel less inclined to offer coverage, particularly if you supply letters of support from a dentist or orthodontist rather than your plastic surgeon. However, focusing on the procedures one at a time and explaining the necessity of surgery now to prevent later surgeries (which they will ultimately have to pay for) may work in your favor. Insurers may also try and classify speech and dental problems that arise as secondary conditions when they are, in fact, direct results of the initial condition, not consequences of the surgery.
Explaining Cleft Lip Surgery to Insurance Companies
Cleft lip surgery may require a team of specialists to diagnose the problem and plan the safest form of surgery. A cleft lip team might include a plastic surgeon, a pediatrician, a psychologist, a dentist, a speech therapist, a social worker, an otolaryngologist, a hearing specialist and a genetic counselor. Unfortunately, some medical insurance carriers may not wish to cover a full team for treating a cleft lip disorder. Reasoning with an authority at the company as to the long-term value of a team (meaning less follow-up surgeries and more one-session surgeries that combine processes) can go a long way in showing the company the legitimacy of your cleft lip claim.
If you are ever denied coverage for cleft lip or cleft palate conditions- don't back down! No one has ever won a victory over an insurance company by backing down—sometimes it just takes will power and a strong sense of reason. You can still seek an appeal even if the insurance company denies coverage and contact the human resources department to explain the problem.
If you exhaust all of your options within the company, you still have various external sources of assistance to turn to for cleft lip insurance claims. Some people who have taken on insurance companies over a cleft lip claim case have consulted attorneys, public officials, media sources, the state insurance commission and non-profit organizations. Three valuable resources that can offer guidance and special information on cleft lip conditions and insurance claims include the Cleft Palate Foundation ( http://www.cleftline.org/ ), The National Craniofacial Association ( http://www.faces-cranio.org ) and the National Association of Insurance Commissioners ( www.naic.org ). Cleft lip and cleft palate surgeries are medically necessary procedures that directly relate to the function of the lips, nose and mouth.