Insurance will not cover implants

The final frontier. Deciding when, if and how.

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needhelp
Posts: 202
Joined: Sun Jan 07, 2018 7:07 pm

Re: Insurance will not cover implants

Postby needhelp » Thu Feb 07, 2019 10:16 am

It just gets worse. I called again my insurance company and again they said no if its an exclusion. I even asked them all these issue were a repercussion from the original surgery that my insurance paid for. They said its in the policy/exclusion that says " for what ever reason", ....wtf..... and to make maters worse I had asked my old gf who was the one that I had the fracture with , if she could help me with a ride picking me up from the hospital because I have no one that I could ask ...... she text me back and said she's met some one...so she said no.... this has been so depressing. I guess you could say I'm struggling right now. Not sure I can even afford the surgery. Dr gave me a price but said he dose not know the full amount because he's not sure how much he has to do with the peyronies.... I was scared as it was but now I've got all this other stuff hitting me ....
61 years old, single, Charlotte NC, Had a penile fracture. Implant scheduled for April 17. Dr Terlecki Winston-Salem, NC

David_R
Posts: 1932
Joined: Mon Nov 02, 2015 1:03 pm
Location: Northeast Maryland

Re: Insurance will not cover implants

Postby David_R » Thu Feb 07, 2019 12:57 pm

Oh, brother, I am so sorry for all the shit you're going through. I will certainly keep you in my prayers (wish I lived closer so I could help in person).
Age 70. Prostatectomy in 2000. My urologist (for over 20 yrs) has been Dr. Marc Siegelbaum of Chesapeake Urology in Baltimore, and Chief of Uro. at Univ. of Md. St. Joseph Medical Center. I have LGX, and have regained my original length. (Not an ad, btw)

Lost Sheep
Posts: 2657
Joined: Mon Jul 04, 2016 11:16 pm

Re: Insurance will not cover implants

Postby Lost Sheep » Thu Feb 07, 2019 1:09 pm

needhelp wrote:It just gets worse. I called again my insurance company and again they said no if its an exclusion. I even asked them all these issue were a repercussion from the original surgery that my insurance paid for. They said its in the policy/exclusion that says " for what ever reason", ....wtf..... and to make maters worse I had asked my old gf who was the one that I had the fracture with , if she could help me with a ride picking me up from the hospital because I have no one that I could ask ...... she text me back and said she's met some one...so she said no.... this has been so depressing. I guess you could say I'm struggling right now. Not sure I can even afford the surgery. Dr gave me a price but said he dose not know the full amount because he's not sure how much he has to do with the peyronies.... I was scared as it was but now I've got all this other stuff hitting me ....

Take notes of every communication you have with your employer about this issue and every communication you have with your insurance company or any representative, physician, advisor, etc. That documentation, with dates and names will help if you need it in a negotiation, court or arbitration. Also, document the injury as fully as you possibly can. The fact that the only witness present now has incentive to stay quiet complicates matters a little bit; approaching her for a witness statement might be problematic, but if you can, that would be good. Be diplomatic.

Do you have a copy of your insurance policy and does it list the exclusions? The fact that your disability (and you should call it that, not "erectile dysfunction") was caused by an injury on a certain date by a certain event (and not by psychology, age or other such cause). If you cannot find the exclusion list, ask whoever told you it was on a list to find it for you. Even if erectile dysfunction is on the list, E.D. caused by an injury is NOT THE SAME as organic E.D. Also, "medical procedures designed to facilitate procreation" are not the same as "medical procedures to restore a lost function". (Note that an injury that limited ankle movement probably would be covered, especially if it required you to use a wheelchair.)

Don't give up. "Illegitimi non carborundum" (Don't let the bastards grind you down". Instead, YOU grind them down. Politely at first. With court-provided sharp (or blunt) instruments if necessary.
Lost Sheep
AMS LGX 18+3 Nov 6, 2017 Dr Shaw.
READ OLD THREADS to ask better questions and better understand answers.
Make yourself part of your medical team.
Document your current penile size: photos and written records.
Pre-op V.E.D. therapy helps.

needhelp
Posts: 202
Joined: Sun Jan 07, 2018 7:07 pm

Re: Insurance will not cover implants

Postby needhelp » Thu Feb 07, 2019 2:21 pm

David_R wrote:Oh, brother, I am so sorry for all the shit you're going through. I will certainly keep you in my prayers (wish I lived closer so I could help in person).


Thank you very much ....
61 years old, single, Charlotte NC, Had a penile fracture. Implant scheduled for April 17. Dr Terlecki Winston-Salem, NC

needhelp
Posts: 202
Joined: Sun Jan 07, 2018 7:07 pm

Re: Insurance will not cover implants

Postby needhelp » Thu Feb 07, 2019 2:22 pm

Lost Sheep wrote:
needhelp wrote:It just gets worse. I called again my insurance company and again they said no if its an exclusion. I even asked them all these issue were a repercussion from the original surgery that my insurance paid for. They said its in the policy/exclusion that says " for what ever reason", ....wtf..... and to make maters worse I had asked my old gf who was the one that I had the fracture with , if she could help me with a ride picking me up from the hospital because I have no one that I could ask ...... she text me back and said she's met some one...so she said no.... this has been so depressing. I guess you could say I'm struggling right now. Not sure I can even afford the surgery. Dr gave me a price but said he dose not know the full amount because he's not sure how much he has to do with the peyronies.... I was scared as it was but now I've got all this other stuff hitting me ....

Take notes of every communication you have with your employer about this issue and every communication you have with your insurance company or any representative, physician, advisor, etc. That documentation, with dates and names will help if you need it in a negotiation, court or arbitration. Also, document the injury as fully as you possibly can. The fact that the only witness present now has incentive to stay quiet complicates matters a little bit; approaching her for a witness statement might be problematic, but if you can, that would be good. Be diplomatic.

Do you have a copy of your insurance policy and does it list the exclusions? The fact that your disability (and you should call it that, not "erectile dysfunction") was caused by an injury on a certain date by a certain event (and not by psychology, age or other such cause). If you cannot find the exclusion list, ask whoever told you it was on a list to find it for you. Even if erectile dysfunction is on the list, E.D. caused by an injury is NOT THE SAME as organic E.D. Also, "medical procedures designed to facilitate procreation" are not the same as "medical procedures to restore a lost function". (Note that an injury that limited ankle movement probably would be covered, especially if it required you to use a wheelchair.)

Don't give up. "Illegitimi non carborundum" (Don't let the bastards grind you down". Instead, YOU grind them down. Politely at first. With court-provided sharp (or blunt) instruments if necessary.


Thank you lost sheep.... your a great help...thank you again
61 years old, single, Charlotte NC, Had a penile fracture. Implant scheduled for April 17. Dr Terlecki Winston-Salem, NC

whostosay
Posts: 6
Joined: Tue Jan 22, 2019 5:44 pm

Re: Insurance will not cover implants

Postby whostosay » Thu Feb 07, 2019 5:26 pm

I worked in Health Insurance for 30 years. I knew most policies inside and out. If the contract lists the implant as an exclusion, it's excluded. There are some exclusions that list exceptions to the exclusion, but unless it specifically includes those exceptions, it isn't covered.

Sorry to be the bearer of bad news.

That said, you indicated that they told you it isn't covered if it's an exclusion. What you don't say is why they lack specifics and used the word "if"?
What do they mean by "if"?
Weren't they quoting the policy when they told you this?

My advice is to get a copy of the policy or "Summary Plan Description" as it's often called. You should read the specific exclusion yourself and not rely on anyone in the call center to answer.
They are boring documents written in language only a lawyer would love but with regard to exclusions, those are written in plain english.

Hope I'm not sounding rude, just trying to be direct. It's a business. They have no emotional ties to your penis, just legal ones....

needhelp
Posts: 202
Joined: Sun Jan 07, 2018 7:07 pm

Re: Insurance will not cover implants

Postby needhelp » Thu Feb 07, 2019 7:04 pm

whostosay wrote:I worked in Health Insurance for 30 years. I knew most policies inside and out. If the contract lists the implant as an exclusion, it's excluded. There are some exclusions that list exceptions to the exclusion, but unless it specifically includes those exceptions, it isn't covered.

Sorry to be the bearer of bad news.

That said, you indicated that they told you it isn't covered if it's an exclusion. What you don't say is why they lack specifics and used the word "if"?
What do they mean by "if"?
Weren't they quoting the policy when they told you this?

My advice is to get a copy of the policy or "Summary Plan Description" as it's often called. You should read the specific exclusion yourself and not rely on anyone in the call center to answer.
They are boring documents written in language only a lawyer would love but with regard to exclusions, those are written in plain english.

Hope I'm not sounding rude, just trying to be direct. It's a business. They have no emotional ties to your penis, just legal ones....


Our systems were down today. I will look at it tomorrow. They did say it was listed as an exclusion. I don't understand if its a medical issue and from the surgery that they paid for last year why wouldn't it be covered. The Dr was upset because he even said it was a medical issue. I'm going to call the insurance commissioner tomorrow and ask them for help. I'm praying they can help me. Im hoping they can make an exception
61 years old, single, Charlotte NC, Had a penile fracture. Implant scheduled for April 17. Dr Terlecki Winston-Salem, NC

whostosay
Posts: 6
Joined: Tue Jan 22, 2019 5:44 pm

Re: Insurance will not cover implants

Postby whostosay » Thu Feb 07, 2019 7:36 pm

needhelp wrote:
Our systems were down today. I will look at it tomorrow. They did say it was listed as an exclusion. I don't understand if its a medical issue and from the surgery that they paid for last year why wouldn't it be covered. The Dr was upset because he even said it was a medical issue. I'm going to call the insurance commissioner tomorrow and ask them for help. I'm praying they can help me. Im hoping they can make an exception

Certainly an option. Best of luck.

needhelp
Posts: 202
Joined: Sun Jan 07, 2018 7:07 pm

Re: Insurance will not cover implants

Postby needhelp » Thu Feb 07, 2019 8:17 pm

whostosay wrote:
needhelp wrote:
Our systems were down today. I will look at it tomorrow. They did say it was listed as an exclusion. I don't understand if its a medical issue and from the surgery that they paid for last year why wouldn't it be covered. The Dr was upset because he even said it was a medical issue. I'm going to call the insurance commissioner tomorrow and ask them for help. I'm praying they can help me. Im hoping they can make an exception

Certainly an option. Best of luck.


You've been in the business. Think there's a chance they could help?
61 years old, single, Charlotte NC, Had a penile fracture. Implant scheduled for April 17. Dr Terlecki Winston-Salem, NC

Skier123
Posts: 68
Joined: Tue Aug 29, 2017 8:10 pm

Re: Insurance will not cover implants

Postby Skier123 » Thu Feb 07, 2019 9:30 pm

A few more thoughts on this thread, in no particular order:

1. Some people can and do "save up" for this procedure. Often the docs will discount their fees for private pay patients.
2. You may be better off financially buying health insurance on your own for a year, and declining your employer's coverage. (you don't want to have 2 "primary" insurance providers, then neither one will pay.) Many (most I think) Blue Cross / Blue shield plans that you can buy on the open market will cover the implant.
3. How much do you like your job? The economy is good right now and maybe its a good time for a job change to an employer who has better health insurance?
4. At the very least, make sure you read you current policy's exclusions with your own eyes. Insurance companies are notorious for discouraging the actual use of the insurance - so don't take anyone's word for it that this procedure is actually excluded until you read it yourself. (With a little digging, I was able to find the actual policy language on my insurance company's website.)
5. Although I have not looked into this myself ... there may be a supplimental health insurance plan that you could tack on to your employers coverage for a reasonable cost that would cover this procedure. It may be worth a call to a reputable insurance broker to find out.
5. Lastly, and I don't want to be too mean here - but all I can say is that once you get over these health-related speed bumps, your next girlfriend is going to be WAY better than your last one ... and you will be much better off in the long run.
54 yr old single guy
Severe ED for over10 years; diagnosed with peyrones and venous leak
Implant surgery scheduled for 12/23/19


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