Question
What is the name of your state? Florida
My 58 yo wife has a cycst in her cheek connected via nerve endings to a bad wisdom tooth.
Three participating Oral surgeons have insisted that when the tooth & cycst are removed, she will need a form of a bone graft to insure her jaw does not fracture.
Aetna refuses to pay for the grafting services or materials and each surgeon has advised they will not perform the procedure any other way.
I've appealed up the line to Aetna without success.
Can some one please assist me with the logistics of a suit for this $6,000+ procedure.
Can I sue them in a small claims court as most attorneys are not interested in taking on such a "small" case.
Any other ideas?? Help, please.
Answer
Many, many health insurance policies specifically exclude oral surgery.
If that is the case here you have no grounds for suit. An insurance carrier is only bound to pay for what is covered under the plan, not every procedure that a medical/dental carrier finds necessary.
Answer
This is medical insurance, correct? And they're denying it on the grounds of this being a dental procedure? They are not required to pay for any procedure which is not covered according to the plan document. Wisdom tooth removal is excluded from medical coverage as it should be covered by dental insurance. Even if you don't have dental insurance, your medical insurance is not designed to cover this type of procedure.
If it's being denied for another reason, reply with detailed description of the reason for denial.
You can try to sue them in small claims court but would probably have to file where the company headquarters is located, and the company would almost assuredly move for a change of venue to regular court, so they could have an attorney present. The reason lawyers don't want to take the case is probably not because it's small (because this would not be a contingency case, you'd have to pay the lawyer an hourly fee), but more likely because they don't believe you can win.
Answer
Thank you for your reply. The carrier is taking the position that the procedure is not medically necessary. Two Oral surgeons have insisted they would not perform the procedure any other way.