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eLearning Series:
Your Most Popular Insurance Questions
Answers For Health and Home
Insurance
( 50 articles
in this series )
Cosmetic Surgery:
Is
It Gonna Be Covered or Very Costly?
How many of us have stood at the checkout
counter of the local mega mart, and perused the tabloids while
waiting for our turn? A staple of many a tabloid is the guessing
game: which celebrity has had cosmetic surgery or perhaps some
liposuction? Yet, what about the lady at the front of the line,
has she had costly surgery?
The term “cosmetic surgery” encompasses a wide variety of
procedures, i.e. liposuction, tummy tuck, nose correction,
face lift, etc. These procedures are not cheap. For example,
a liposuction, which is essentially a fat reduction procedure
in the areas of the thighs, hips, abdomen, knees, and face,
may cost between $1,500 and $6,000. A face lift, which is the
tightening of the skin and facial muscles while excess skin
is removed, runs from $2,500 to $8,000, and quite possibly
higher.
In
general, insurance companies do not cover cosmetic surgery
unless it is deemed to be medically necessary. Medical necessity
is not always easy to ascertain, but as a rule of thumb, if
the cosmetic surgery to be performed necessitates reconstructive
surgery in the wake of trauma, tumors, infection, developmental
abnormalities, or congenital disease, the patient will have
the good fortune of having the insurance company foot the bill.
Conversely, if the patient is not able to establish medical
necessity, the insurance company will consider the treatment
to be an elective procedure and will not be obligated to pay
anything.
So as to qualify as a reconstructive surgery rather than an
elective cosmetic procedure, the operation must be
performed in order to improve a body part’s functions, but quite often
it is accepted if the surgery is merely used to give the body
part a societal accepted normal appearance. Yet, the buyer
must beware! While insurance companies will quite often cover
such reconstructive surgery, they may not cover it to the extent
the patient wishes the surgery to go.
One of the procedures that are quite often covered is ear
surgery, also known as otoplasty. In the course of this surgery,
prominent ears are set back to lie closer to the head; in some
cases, the size of overly a large ear is drastically reduced.
When this surgery is done on children, the insurance companies
quite often cover it; when it is done on an adult, the patient
will have the obligation of proving the reconstructive aspect
of the treatment as opposed to the cosmetic angle.
Another cosmetic surgery that may be covered by insurance
is eyelid surgery (blepharoplasty), which corrects drooping
upper eyelids, or puffy bags below the eyes. This is accomplished
by removing fat, skin, and muscle that cause the undesired
drooping/puffing. This surgery may be covered if the patient
can prove to the insurance company‘s satisfaction that it is
deemed to be medically necessary to correct visual field defects.
Nose
surgeries, also known as rhinoplasties, accomplish a
wide variety of effects, such as the reduction or increase
in the nose’s size by simple reshaping, the removal of a prominent
hump, or the correction of a previously broken nose. If the
surgery is a reconstruction due to damage to the nose, it will
most likely be covered by the insurance company. Otherwise,
the patient will need to establish that the procedure is not
simply an esthetically motivated treatment, but actually offers
a medical benefit, such as the relief of breathing problems.
Insurance companies in many ways still have the upper hand
when deciding whether or not to cover a cosmetic surgery. Policies
are plentiful and vary from plan to plan, yet the American
Medical Association and the American Society of Plastic Surgeons
set a guideline that is generally followed forth.
If the aforementioned entities declare a procedure to be a
reconstructive surgery, which does not necessitate a causal
event but may easily apply to a simple improvement of function
of the body part in question, then the insurance companies
will be more likely to consider the claim for payment. If,
however, a procedure is considered devoid of medical benefits
and is simply deemed elective for the sake of improving a patient’s
self-esteem or body image, the insurance companies will be
very hesitant to even accept the claim.
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SolveYourProblem.com : 2005
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