I need explant surgery and my private health insurer is refusing coverage - what can I do?

Introduction

It’s a common story - you had breast implants and after a short time, even a year or two, you started getting very sick. You stop being able to think properly, you have brain fog, tiredness, depression, fatigue, an inability to work.

You start having different procedures, have tests done, visit your naturopath, and then after a while you realise that it was your breast implants all along. You make the decision to get surgery to have them taken out, but you don’t have the money to have explant surgery.

Thankfully, there are a number of options open to you.

Rise focuses on helping women gain access to breast implant warranty, insurance funds, Medicare and superannuation.

In this article we discuss what you can do if your private health insurer won’t cover you for explant surgery.

As a quick summary, we explain that you should be gathering the following information:

Checklist

  1. Report from your surgeon who recommended the treatment

  2. Report from your surgeon who conducted the treatment

  3. Report from your general practitioner

  4. Report from any other treatment provider who is of the view that the removal of your implants is medically necessary.

  5. Clinical notes from each of your treatment providers mentioned above

  6. Any photographs and other supporting documents showing the surgery and/or rupture if applicable.

  7. Evidence of treatment expenditure related to your medical condition and explant surgery

We explain how you can go about getting this information to give yourself the best chance of coverage. Or, contact us and we can do it all for you.

If you have private health insurance that is refusing coverage for your explant surgery and associated costs, it can be very frustrating.

We provide this guide as an easy reference to help you understand the insurer’s process, and to explain the steps you can take to give yourself the best chance of recovering the full amount of your expenses from your private health insurance company.

Of course, this information is not legal advice and is provided as general information for you. In order for us to give you legal advice on your situation and help you gain access to your specific insurance policy, you will need to contact our offices.

So, let’s begin:

1. First thing’s first: the basic principles of insurance companies

You have an agreement with your insurance company

You have a contract with your insurance company. That’s what you pay premiums for.

The company has to abide by that contract.

If the insurance company promised to cover you for certain types of surgery for a covered ‘event’, then it has to do that.

When you try to get the insurance company to make payment for your explant surgery under the policy, you are enforcing the contract that you have with the insurance company.

It’s not personal

Insurance companies aren’t personal. They have policies and wording that they have to apply, and they will usually provide coverage if you can fit your particular situation within their policy wording with your evidence.

Persistence can make a difference. We have spoken with women whose insurance companies refused their coverage four times and approved it on the fifth time.

2. Gather the evidence

It can help to think about your claim for insurance coverage like a judge. If you were a judge, assessing whether you, personally, really should be covered under the policy, you would want to see evidence, like doctor’s reports, to understand more about your case.

The more evidence you can gather to support your case, the better.

The Key issue: Prove you are covered for the event under the policy

In order to provide you specific advice on coverage for your particular police, Rise Lawyers will need to see the precise policy documents and understand the type of coverage that you have.

However, generally speaking, you will usually need to prove that your treatment was medically required.

If your insurance company and Medicare classify your treatment as cosmetic, this, by definition, means that it is not medically necessary, and you will likely be refused coverage unless you opted for a higher level of cover which specifically covers you for cosmetic surgery.

If you gave applied for the higher cover, then your policy documents should reflect that.

3. What is ‘medical necessity?’

Medically necessary, means health-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms that meet accepted standards of medicine.

Ultimately your treatment providers are the ones that are best people to prove that something is medically necessary. So, whether something is medically necessary will depend on your treating doctor’s opinion.

You will need to gather evidence, from your treatment providers, which can be provided to the insurance company to demonstrate that in your doctor’s opinion the surgery is medically necessary.

You cannot change your surgeon’s opinion, but you can often speak with your surgeon, and if you explain the need, it is likely that they will be wiling to assist you by providing a report or other evidence to show that the treatment is medically necessary in a form that the insurance company will accept.

4. What type of evidence should I be getting?

Strong and convincing evidence can be medical reports and records.

You can seek out reliable, reputable medical evidence about your personal situation.

Although we know that many other women may have unfortunately been in your position, their evidence will not benefit your claim.

You need to focus on your specific case, and why you, specifically, should have coverage. So, focus on your specific situation.

5. Who should I get reports from?

Insurance companies think in terms of hierarchies. They are more likely to give weight to an opinion that is from someone with many reputable and established qualifications with a higher level of training, qualification and experience, than someone who has less.

Equally, insurance companies are more likely to give weight to an opinion from the doctors and treatment providers that actually recommended and conducted the surgery.

There is no hard and fast rule, but you should aim to get reports from the following people, in order of priority, who were involved in your treatment:

  1. Your surgeon who recommended the surgery.

  2. Your surgeon who conducted the surgery (if they are the same person, all the better).

  3. Your General Practitioner who provided you with a referral to the surgeon

Any additional specialist that you have been referred to, including:

  1. Immunologist,

  2. Pathologist,

  3. Rheumatologist,

  4. Physiotherapists.

  5. Chiropractors.

  6. Other treatment providers.

If you can get a report from all of these treatment providers, then that is excellent and will give you a much stronger chance of recovery.

6. What should the report say?

Now comes to the more challenging part – you will need to read your policy wording.

You will need to go back to your policy wording and confirm what the policy wording requires when providing coverage.

You should remember that insurance companies rely upon established evidence. So, whilst breast implant illness is not currently recognised as a medical disease accepted internationally, other conditions related to breast implant illness are. For example – a ruptured breast implant.

So, whilst you may be suffering from breast implant illness, but that condition is not under the policy, a ruptured implant is ordinarily an accepted condition requiring explant surgery, and so it can be helpful to focus on the conditions that the insurance company will accept. We discuss rupture in more detail later in this article.

Rise Lawyers have special letters which are drafted to give you the best chance of gaining access to your insurance policy, from your doctor.

7. Be very careful about cause and effect

You should also note that it can be very difficult to establish that certain vague symptoms that may suffer from are, or have been caused by your breast implants.

So, for example, a report that confirms you are suffering from Lupus, will not necessarily be of assistance to you, because your insurance company may argue that the implants were not the cause of your Lupus, therefore, again, it is important to focus on the obvious conditions lined to breast implant problems, such as rupture.

Generally, the following letter template has been of assistance to ladies in the past to prove that their surgery was medically necessary and should have been covered under the policy.

8. What else can I provide to support my position?

To increase your chance of coverage, we recommend that you gather as much evidence as possible.

If your explant surgery has already happened, you can call your surgeon, and ask for your entire clinical records, which should, ideally include:

  1. Surgery report

  2. Photos from the surgery

  3. Pathology

  4. Any notes taken by your surgeon during the procedure.

If you have yet to have explant, then you could attend your general practitioner and explain, in great detail, all of the issues that you are suffering from. Do not hold back. If you are having pain in your breasts, explain that to your GP. If you are concerned about the risk of cancer, you can explain that. If you think that you have a rupture – this be recorded in the clinical notes.

This can establish a record within your treatment provider’s clinical notes of your genuine concerns and complaints linked to your breast implants to allow yourself to have treatment, to assist with the provision in the future, to fully inform your treatment provider so that they can help you in the future and to allow that record to be referred to later if the records need to be used as supportive evidence.

You should note that your clinical notes may not be supportive of your claim, because, for example, they do not identify that you suffer from any condition covered in your insurance policy.

This document does not provide you with legal advice on your particular condition or situation. We do have lawyers who can provide you with that advice and assistance and we recommend that you contact Rise Lawyers to engage a lawyer to assist you in this process.

9. Evidence of a rupture

Given a long enough timeframe, all breast implants, no matter the style, material, or brand, will suffer a rupture.

Rupture can be microscopic – that is, gel bleed. Or it can be global – that is, a complete collapse and deterioration of the implant.

As we have noted above, most insurance companies will provide you with coverage and deem your explant surgery medically necessary if you can prove that your implant was ruptured and that your surgeon recommended that it was medically necessary to have it removed due to a risk to your health.

You can establish ruptures through a variety of means:

  1. A MRI scan

  2. An ultrasound

  3. A report from your surgeon that in their opinion your implants have ruptured.

If you can gather evidence of a rupture by reputable means, and demonstrate that the rupture made it medically necessary to have your implants removed, it is much more likely that your company will be willing to provide you with coverage under the policy.

But they are only covering certain expenses!

Your insurance company will have different levels of coverage. You will need to look at the level of coverage to see what you are entitled to recover. For example, you may only be insured for a maximum amount.

You need to provide the following documents to gain full coverage of your loss:

A clear schedule identifying all receipts that show expenditure, by you, for the explant surgery; including:

  1. Surgeon’s fees

  2. Anaesthetists fees

  3. Hospital fees

  4. Transport costs associated with treatment

  5. Supporting bras, drains and other equipment used after explant.

  6. Medication bought for recovery

The insurance company needs hard evidence and original receipts, if possible, to show the precise expenditure that you have incurred. The more evidence, the better your chances of recovering it all.

Checklist

So, in summary, we provide this easy to use checklist to confirm that you have done all that you can to get the coverage that you are entitled to under your private health insurance policy to undergo explant surgery.

  1. Review of policy wording

  2. Gather the following evidence to show that the explant surgery is medically necessary as recommended by your treatment provider:

  1. Report from your surgeon who recommended the treatment

  2. Report from your surgeon who conducted the treatment

  3. Report from your general practitioner

  4. Report from any other treatment provider who is of the view that the removal of your implants is medically necessary.

  5. Clinical notes from each of your treatment providers mentioned above

  6. Any photographs and other supporting documents showing the surgery and/or rupture if applicable.

  7. Evidence of treatment expenditure related to your medical condition and explant surgery

If you need help preparing these documents, or just want a solicitor to give your insurance application a look over, don’t hesitate to contact us and we can help to give you the best chance of gaining coverage under your insurance policy.