Health Insurance Denial when Previously Pre-Certified

[rjhicks]

YOUR STATE NAME - Missouri

I have health insurance through a health plan in Mississippi. 2 and a half years ago I got a Orthognathic Surgery pre-certified. The certification was fine but it did indicate that it was only for 6 months. However, based on this I got braces put on to begin the long process of Orthodontics before I could have the surgery. Then I did a second pre-cert on the surgery at the end of last year and it also went through but it expired 12/31/2001. Then this year I am finally ready for the surgery and we sent throught the pre-cert again and they say it isn't covered as of 1/1/2002 of this year! Now here I am with my bite more messed up than it was 2 and half years ago and I can't get the surgery because it is no longer covered.

The insurance company should know that this type of surgery is always preceded by years of ortho and I can't believe that they would not "grandfather" people who had begun the treatment leading up to the surgery. Do I have any legal basis to fight them?

Thanks.

 

[cbg]

Depends on a lot of factors. Did the insurance carrier change their overall policy, or did your employer ask to have the benefit removed? If the carrier, did they change it as an across the board benefit (as in, we're not going to cover this for anyone anymore, ever) or did they stop it for your company alone? If your employer, did they do it because the benefit was making their premiums too high? Was the decision to drop the benefit made because of changes to your state insurance law? Does your state insurance commission require grandfathering?

 

[rjhicks]

Actually, the insurance company and the employer are one in the same. I actually work for the insurance company. I do not know if my state insurance commission requires "grandfathering". I guess I need to find out where I can get that information.

Thanks.