Penalised for penile surgery

Insurance Helpline - With Cedric Stephens

Question: I underwent a radical prostatectomy recently. As a direct result of that operation, I am now experiencing erectile dysfunction. A New York surgeon has consented to perform a penile implant. The estimated cost is US$30,000. I sent the estimate to my local health insurance provider. A clerk in the company's office told me that their coverage does not cover this procedure. I am puzzled by this statement. My present condition was caused by the prostatectomy. The company paid for this procedure without any questions. Yet they are denying my second claim, which has become necessary as a result of the first surgery. Please investigate and advise me.

- Initials and address withheld at reader's request.

Answer: I am sorry to learn about your condition and the problem that you are having with your provider.

May 16-21 this year was declared Insurance Week. As I thought about your question, I recalled the feature published in this newspaper headlined "The importance of health insurance." This type of coverage was called "the most important type of insurance." The article argued - quite properly in my view - that without insurance "an illness or accident can wipe you out financially (as is happening in the USA and also in Jamaica) and put you and your family in debt for years ... ."

uncaring insurance company

The letter the insurance company wrote to you denying liability for the second surgical procedure struck me by its cold, matter-of-fact and uncaring tone.

The writer, in spite of all her professional qualifications, displayed 'poor bedside manners' like some doctors. She ignored your state of mind and that you and your family could be facing financial ruin. Money had to come from somewhere. The second operation is absolutely necessary.

I sent the following email to your health provider's head honcho after you authorised me by telephone to contact them:

"Mr ... is currently in the US undergoing a medical procedure ... to correct erectile dysfunction, which resulted from a radical prostatectomy. He asserts that the procedure, which involves the insertion of a penile implant, occurred as a direct result of the prostatectomy. He feels that medical costs associated with the implant should be borne by your company under his group health plan in the same fashion as the costs of the prostatectomy ... ."

claim denied

"Your company's letter dated May 4, 2010, states: "Unfortunately, we are unable to grant approval as this is not a covered benefit under the group health insurance plan. The claimant is, presumably, ignorant about the provisions of his group health plan and the technicalities of a 'covered benefit.' Can you please undertake a review of this claim and provide me with a written explanation - in non-technical language - why was the claim for the second medical procedure excluded when your company was aware that a radical prostatectomy almost always results in erectile dysfunction? Should you not have anticipated this and proactively dealt with the situation in a caring way when the first claim was paid? Has the company properly discharged its moral - as opposed to its contractual - obligations?"

I was pleasantly surprised to receive the following response from the company, one day later, saying the claimant "has coverage under the Government Employees Administrative Services Only (GEASO) Plan - both as an employee and also as a dependent. ... The fact that it is an ASO plan means that the Government is responsible for all claims costs related to the administration of the plan ... . Government has put a monitoring committee in place to - as the name suggests - monitor the administration of the plan.

"The Schedule of Benefits approved for administration under the GEASO plan does not include coverage for penile implants, whether following prostate surgery or not. (The company) does not have the authority to approve benefit payments outside of the guidelines laid down in the Schedule of Benefits.

"Government has put in place a 'special consideration' process. Any member under the GEASO plan can put forward a request for additional benefits to be paid as a 'special consideration'. We play no part in the process other than to administer the requests, that is, put the submissions to the committee and carry out the decisions taken by the committee. (The claimant) may put forward a written request for benefits to be paid for this procedure under the special consideration process. The request may be directed under private and confidential cover".

The insurance company administers or manages the health plan on behalf of the GOJ, the plan sponsor. ASO means administrative services only. Risks associated with the plan are borne by the GOJ - not the insurer.

The plan structure or schedule of benefits and other important decisions are made by the GOJ. The provider only executes the decisions of the plan sponsor and pays the claims in exchange for a fee.

I hope that the second procedure is successful and that your case for reimbursement will be favourably considered.

Cedric E. Stephens provides independent information and free advice about the management of risks and insurance.aegis@cwjamaica.com Text (SMS) message to 812-7233.