Lipedema Treatment Insurance Coverage Denials
Previously, we’ve addressed more general whether your claim has been unfairly denied. However, there’s something wrong with the insurance industry when you can’t get coverage for a known, effective treatment for your disease. Getting help paying for expensive treatment when we need it is precisely the reason we all sign up for health insurance in the first place. As the 11% of women who suffer from lipedema are beginning to find out, your health insurance company is not always there for you when you need them. This article addresses what lipedema is, how it is treated, why insurance companies try to deny coverage for treatment, and what can you do about it if you are one of the millions of lipedema sufferers in the United States.
What is lipedema?
According to the National Institutes of Health (NIH), lipedema is “a disorder characterized by symmetric enlargement of the legs due to deposits of fat beneath the skin.” The NIH describes lipedema as a common condition that occurs “almost exclusively in women” and affects up to 11% of women worldwide.
Lipedema is a progressive disease that gradually worsens as it progresses through four different stages. It is a painful disorder, and sufferers are subject to easy bruising, limited mobility and a grossly deformed appearance first in the legs but later in the arms and upper body as well.
How is lipedema treated?
Various therapies may help alleviate some of the swelling and other symptoms of lipedema, including diet, exercise and complete decongestive therapy. An effective surgical treatment is tumescent liposuction, which involves injecting the affected areas with a solution of epinephrine and lidocaine, allowing doctors to remove large amounts of fat during the procedure. Multiple surgeries may be required to treat the condition.
Why do insurance companies deny lipedema treatment and coverage?
Many insurance companies deny all forms of liposuction as a “cosmetic surgery” that is not performed for therapeutic purposes. This obviously is not the case with tumescent liposuction used to treat lipedema, but insurance companies nevertheless issue blanket denials of liposuction for any reason. Some may think that insurance companies know better and are acting in bad faith, hiding behind their policy language to avoid having to pay for surgeries for the millions of women afflicted with lipedema.
What can you do if your claim for coverage is denied?
The first step in fighting a denial of coverage is to appeal the decision to higher levels in the insurance company. This requires providing a great deal of documentation and reports from your doctors showing that liposuction is an accepted, effective method of treating your diagnosed medical disorder. You’ll also need to be able to understand your insurance policy’s complex, technical language and argue against the insurance company’s wrongful interpretation of its own policy. You’ll likely need the help of an experienced insurance lawyer who knows how to request the appropriate documents from the insurer and can “speak their language” when appealing a denial of coverage.
If appeals to the insurance company are unsuccessful, you may need to institute litigation to get results. One option is a bad faith insurance lawsuit. If successful, you can receive an injunction from the court forcing the insurance company to cover your treatment, or money damages such as reimbursement if you paid for the procedure out of pocket. Another option is to bring a class action lawsuit on behalf of all women who have similarly been denied coverage for treatment of their lipedema. A class action lawsuit settlement can not only result in you getting the surgery you need, but it can also force insurers to change the way they cover liposuction or other treatments for medical conditions.
In either situation, make sure you contact an experienced lawyer or law firm that focuses its practice on suing insurance companies for bad faith. Insurance Bad Faith is a specialized area of the law that requires particular expertise, experience, and the resources and determination to go up against the insurance giants. You should also look for an attorney who understands lipedema and has handled cases similar to yours.
Lipedema treatment is expensive, and most people cannot afford to pay for surgeries out of pocket. This is why we buy insurance. We pay premiums every month, year after year, and we rightfully expect coverage and benefits to be available when we need them.
