Breast Reduction Exclusion - Discriminatory?

[Guest AllanB]

Can a Self-funded welfare benefit plan exclude breast reduction as an eligible benefit even if medically necesary? Would such an exclusion be considered discriminatory? Such an exlcusion would not be applied to mastectomies, only breast reductions.

[KIP KRAUS]

Allan:

Unfortunately, I think a self-insured medical plan can deny coverage for any specific medical procedure for which they wish to do deny. One of the main reasons for having a self-insured medical plan is to avoid mandated state group insurance coverages. As an example, many states mandate coverage for psychiatric coverage (which in most cases could be argued to be medically necessary), but a self-insured plan can specically deny, or limit such coverage. On the other hand, if the self-insured plan document/SPD does not specifically deny coverage for breast reductions, and defines plan coverage as covering procedures that are not experamental in nature and medically necessary, I would say your client should appeal the denial. Have her folow the appeals procedure set up by the plan.

Good Luck

[jeanine]

Kip is right in most respects. The only coverage a self-funded plan has to offer is that coverage mandated by federal law which amends ERISA and certain other federal nondiscrimination laws. There are very few mandates (HIPAA, WHCRA, NMHCA, COBRA to name a few) and this benefit, to my knowledge at least, has not been litigated under any of the nondiscrimation statutes. Not too long ago, one of the large insurers had a high profile case in which they refused to cover a breast reduction in a 17 year old male and relented only after extreme public pressure and media coverage. The place to look for this exclusion is in the explanation of benefits. If the SPD states that benefits are provided pursuant to a schedule of benefits and the schedule is provided to the enrollee, then the exclusion will stand even if the procedure is medically necessary. Perhaps the physician can exert some pressure on the plan reviewer if the matter is one of extreme medical necessity that would take it out of the realm of automatic exclusion.