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New York Mom Beats Insurer on $27K Surgery Denial
6 Nov
Summary
- Aetna denied coverage for a child's $27,000 surgery, citing cosmetic reasons.
- An external review overturned Aetna's denial, deeming the surgery medically necessary.
- A majority of external appeals in New York State are overturned, reversing denials.
In New York, a state-appointed organization offers recourse when health insurance companies deny necessary care. Nadine Friedman successfully utilized this external review process to overturn Aetna's denial of coverage for her son Ozzie Roberts' $27,000 surgery.
Ozzie, who has Goldenhar Syndrome, required the surgery due to pain and growth issues. Doctors confirmed its medical necessity, yet Aetna classified the procedure as cosmetic, leading to a lengthy appeals battle. Friedman fought the denial, eventually securing coverage after an external review reversed the insurer's decision.
Research indicates that a majority of external appeals in New York are overturned, with 52% of denials reversed last year. This suggests potential issues with initial insurer decisions, including errors or policy ambiguities. Despite the system's effectiveness in some cases, the arduous nature of the appeals process remains a significant challenge for families.
Advocates like Friedman are pushing for federal changes, such as the Ensuring Lasting Smiles Act, to mandate insurance coverage for treatments related to congenital anomalies. While insurers note the importance of peer-reviewed evidence and guidelines, the struggle for necessary medical care continues for many.
