When health insurers play games, patients lose

A doctor jumps through numerous hoops to get UnitedHealthcare to pay for a patient's breast reduction — only to finally be told the surgery wasn't covered by her policy.

  • Pin It

Dr. Theodore Corwin, a plastic surgeon in Thousand Oaks for the last 30 years, has had run-ins with insurers before, but never one so aggravating — and pointless — as this.

A 26-year-old woman recently came to his office complaining of back, neck and shoulder pain, as well as numbness in her hands and arms, resulting from her unusually ample bust. She's 5-foot-6, not overweight, Corwin said. She wanted a breast reduction.

"There seemed to be no question that her pain and numbness was caused by her carrying this excessive weight," Corwin told me. "It seemed like a straightforward diagnosis."

It wasn't, at least in the eyes of the young woman's insurer, UnitedHealthcare. Its response to both a policyholder and her doctor speaks volumes about the seeming priorities of our for-profit healthcare system.

"It's clear that there are some types of claims that are routinely denied," said Shana Alex Lavarreda, director of health insurance studies at the UCLA Center for Health Policy Research. "They might not even look at the policy until the doctor follows up."

Corwin said he contacted UnitedHealthcare after his patient's visit to receive authorization for the operation.

He heard back about a week later: The treatment wouldn't be covered.

Corwin said UnitedHealthcare wasn't convinced that the woman's condition impaired her ability to function normally. It wanted more evidence that her symptoms were related to her figure.

So Corwin drafted an appeal describing how the woman was unable to fully lift her arms, which affected her performance at work, and how she had difficulty carrying things because of the tingling in her hands.

He also included the results of an MRI showing a central disc protrusion on the woman's spinal cord — commonly known as a slipped disc — that appeared to be caused by the weight of her breasts.

"Neck pain, headaches and pain in the face, shoulders, arms and hands may be created when the disc protrusion presses on the neck nerves," says the website of Britain's Spinal Foundation.

"This may cause numbness or 'pins and needles' in the face, shoulder, arm or hand, and may also be associated with weakness of shoulder, elbow, wrist or hand movements," it says.

Corwin said UnitedHealthcare got back in touch to say it wasn't happy with the photos he'd sent in of his patient. It wanted new ones.

He had new photos taken and sent them to the insurer.

Finally, UnitedHealthcare made up its mind: The treatment wouldn't be covered.

But this time, the decision had nothing to do with questions of impaired functionality, protruding discs or unsatisfactory photos.

"They said the patient has a specific plan that excludes any breast surgery that isn't covered under the Women's Health and Cancer Act," Corwin said.

That 1998 law applies only to women with cancer who elect to have breast reconstruction surgery after a mastectomy.

Needless to say, it's bad enough that an insurer would include fine print like this in any woman's health coverage, not to mention that treatment would be denied for what appears to be a valid medical complaint.

But Corwin also was left wondering why UnitedHealthcare didn't just say at the outset that it had inserted this weaselly provision into his patient's insurance policy.

  • Pin It

Local & National Video

Local & National Video