Come Wednesday our family will be out $35,000 for our daughter's medically necessary surgery.
I didn't read the 'limits and exclusions' when we signed up 7 years ago since her condition was not present then. Our family's premiums are $820/mo.
This is a University of Texas plan that excludes orthognathic surgery unless the insured is on the policy since birth. The Texas Insurance Comissioner has no jurisdiction since the UT plan is self-funded.
If this is not done our daughter will live a life of chronic pain (unable to eat without pain, unable to sleep through the night with over-the-counter pain medication), inability to process her food (her back teeth do not meet anymore) and a speech impediment (her tongue being boxed into a too small space due to the overgrowth of one side of her jaw).
Her oral/maxillofacial surgeon with whom she has had a 3 yr. patient relationship stopped taking insurance a year ago so I knew that I would have to pay him upfront $15,000 and collect from my insurance.
more below the flip
I can't tell you how upsetting this surgery is for us and now the added burden of covering all the fees. BCBS has told me if there are complications of the surgery AND they can be substantiated by the medical record then they will pick them up.
I feel like I've been kicked in the gut. Our safety-net of insurance is gone.
I have one chance on appeal which I have filed. We have second and third opinions on this. All strongly support this claim (in fact, they feel as let-down as we do that this is not covered. Their medical expertise is being questionned).
This is definitely not a plea for funds. It is a hardship for us but we can and will pay. Although if anyone has any ideas for the appeal which is one shot and final- I would appreciate it.
This is simply a cautionary tale from a family that thought they were insured.