Coverage

We are writing about our son Cory, who was born with a port-wine stain (birthmark) on the right side of his face covering his right eye.  At first our pediatrician told us  that it would probably go away in time. We were not satisfied with this and asked the doctors to check into this to see if anything could be done to correct it.  What we found out was that it would not go away on its own. It would get worse as he grew older. Two procedures needed to be performed . 1) MRI to determine whether or not he would develop seizures because part of the port-wine stain was on the side of his head. and 2). Eye examination to rule out glaucoma because the stain was also covering his eye and it was known that glaucoma could develop.  We were elated to find that both test came back negative.  Our next step was to find a reprepal doctor who would perform  laser surgery to remove the port-wine stain.   This procedure was performed using the candela pulsed-dye laser.  Our pediatrician found a doctor for us in the Miami area which was a considerable distance from our house ,but we did not know of any other doctors who performed this type of procedure.  When we did decide to go ahead with the surgeries, that’s when our trouble with the insurance companies began.  They informed us that his condition was cosmetic and they were not going to cover the procedures. While trying to fight them we continued with the surgeries and after 3 surgeries ,due to the change in insurance’s at work, we  had to switch insurance companies finding ourselves back at the beginning starting a whole new fight!. This time our luck would change because we came upon a doctor in  St. Petersburg whose insurance person helped us out a great deal. She gave us papers to send to the insurance commissioner and told us to try this route! Even though we weren’t able to have this doctor perform laser surgery due to insurance reasons,,, again!  We contacted the insurance commission of Florida and they instructed us on what to do. They told us it was very important to do what our HMO wanted to do as far as following their grievance procedures, going to their meetings etc.. They also told us to fill out the forms they had sent us and our complaint would be handled by  a committee who works for the people. We were at a point where we were willing to try anything. We heard from the Insurance Commission Committee several times over  the months informing us of the repeated denials from our insurance HMO, also we were still  going to grievance procedures one after the other giving them our complaints each time. This went on from January until June of 1996. Our family was beginning to feel our frustrations so my sisters suggested that we contact the local news channels for help. My sisters  researched Cory’s condition and compiled several sheets explaining the medical necessity along with our recommendations from 3 well known doctors stating that it is medically necessary!   We made several copies with pictures, and sent them to our insurance company, the Insurance Commissioner, and was told by the New station to send them a copy. We informed our HMO that we had contacted the Media and that seemed to work! Within 3 days of  informing our HMO what we had done. We received a certified letter in the mail stating they would cover Cory’s procedure FULL COVERAGE!!  We were elated! Finally we got what we fought a year for, and in August of 1996 Cory had his 4th laser surgery with a wonderful physician who is still treating Cory with the pulsed-dye laser. Cory is 2  1/2 years old now, and has had 11 laser surgeries.  His next surgery is Jan.15,1998. We will have before and after pictures posted. If you have any questions or  if you are going through the same problems please e-mail us and we can talk more.

 

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