I thought I was lucky when I had my DIEP reconstruction, done under my employer’s health insurance plan. The result has been quite successful; however the reconstructed breast is bigger than my unaffected breast. The solution seems obvious, reduce the reconstructed breast to gain balance….oh no it’s not that simple. It appears that (and I’m sure this will apply to others so beware!) they will enlarge, reduce and/or uplift a ‘normal healthy breast’ but it appears that they will not pay for any alteration AT ALL on the reconstructed breast.
I really thought I’d researched everything as well as I could before entering into this operation. But now am left in limbo with one boob bigger than the other! I am going down the complaints procedure but have been declined twice now. Has anyone else experienced this and managed to get the situation resolved? I would really appreciate any assistance I can be given.
While you wait for other forum users to reply, I wanted to remind you about Breast Cancer Care’s Helpline, which offers support and information. Calls to the helpline are free, lines are open Mon to Fri 9am - 5pm and Sat 9am - 2pm Tel: 0808 800 6000.
I think Insurance companies are a nightmare. I had my TRAM flap done which my insurers agreed to. Like you I now have one bigger than the other. My insurers will not pay for any work to be done on the ‘good’ breast as they deem this to be cosmetic. They have suggested that i get the PS to write to them informing them the proportion of surgery that is necessary as a result of the cancer treatment! As far as I am concerned I would not have had surgery at all if it wasn’t for the bc.
This is just a thought as I know nothing about the workings of PHI compannies. As far as I understand what you are saying they wont allow further surgery to the reconstructed breast but would to a normal breast!!! Can you not do it on the grounds the the work that needs to be done is on ‘incomplete’ surgery?
Lois your company seem to be saying the opposite that they WONT pay for work on good breast.
Hi,
the first thing you need to do is to get your plastic surgeon to write a letter to the insurance company saying that further surgery is necessary to complete your course of treatment ie that it is part of your original course of treatment and not additional treatment - I am presuming he/she has agreed to do another op to balance you out? if they then still refuse to fund it then providing you have gone through all the steps of their complaints procedure you can take it up with the ombudsman - I had to go down this route for a similar matter but be warned, it took the ombudsman near on a year to uphold my complaint and instruct the insurance company to pay out.
Just out of interest, can you not get this done on the NHS?
I don’t have any personal experience of private healthcare but I would say that common sense says that getting the DIEP’d breast to the right size is part and parcel of the original job. However, it doesn’t surprise me that an insurance company would try and wriggle out of anything it thinks it might get away with.
Alternatively, could you not have the alteration done on the NHS? Does the same surgeon who did it privately not do exactly the same sort of operation for the NHS? It might be worth getting on the NHS waiting list as a back up option.
I had a reCON on the same side twice because of incompetence. The revising surgeon wrote a very strongly worded letter to the insurars and they paid up 2nd time, no questions asked which:
shows what a botch the first surgeon made
what a good and concise case (I have a copy) the second surgeon put forward
Don’t be put off, go back to them and the surgeon and get the right words down on paper.
Hi Ladies
I’ve had all my treatment privately and am sorry to say can only confirm the same experience as the others. My DIEP was only partially covered so we were £1500 out of pocket and since then I have had numerous problems with the recon. I am now totally asymetrical and am booked in for a mastopexy to lift the unaffected side. A procedure which I NEVER would have considered prior to BC but the insurance company deem this as cosmetic and will not enter negotiations at all!. I need to have more work done on the original recon as there is really bad fat necrosis and scarring from a wound which refused to heal whilst I was on chemo. The PS has had to write a letter to the insurance company and lay it on thick that there is a medical reason for requiring the necrotic tissue to be removed, they have agreed to fund me for one procedure. The PS ideally would like to do several procedures and involve some lipomodelling but the insurance comapany have made it clear I am getting one procedure only and then as the others said the rest is ‘cosmetic’. To be honest I haven’t got it in me to keep going back to theatre anyway and have made this clear to the PS so he is going to do what he can in my ‘one’ opportunity but I agree with the others it is frustrating as I would never have considered PS to my boobs if they hadn’t been ravaged during the battle!
To those who have been turned down privately for more work, can you ask your PS if it can be dome on the NHS? The way I look at it, I have saved the NHS 000’s of pounds by being a PP in the first place??
I am in a similar siuation and becoming increasing angry as I wasn’t made aware that this situation could occur prior to surgery and I complained also requesting their policy and advisor training be reviewed so other unsuspecting ladies don’t fall into this black hole or at least are made aware of it before falling in! But in return letters to me they are making out I was aware; so it’s my fault and that their training and policy are fine as they are!
They too have said that any amendment to a reconstructed breast is deemed cosmetic! What planet do they live on when their policy offers reconstruction but then stops whilst still incomplete?
I am at the second stage of complaining now…still no luck. My surgeon has written to them stating what work I require, but they still keep saying the policy doesn’t cover it…tough titties! I had never entered this for ‘cosmetic enhancement’ I just wanted to achieve a boob the same as before my mastectomy…not be left lop-sided as I am now!
Could I have it finished on the NHS? But I also think it’s very unfair that the NHS should have to pick up on work that the private sector rejects.
Llamalois – what are you proposing to do now?
Eal69eal – Did you know of your policy restrictions before your surgery and have you used the insurance company’s complaints procedure?
Has anyone has been successful after complaining! It wears me down all this letter writing and worry!.
I agree with everything that you have all said, the insurance companies are not even consistent, let alone fair. I was not informed about their rules regarding so called cosmetic surgery until i had had my mastectomy, so I just decided to take it one step at a a time. Now my 10 week old TRAM is healing ok I have asked the PS to write to the insurers detailing the proportion of surgery still required on each side and then i intend to negotiate with them to pay a percentage of the costs my self if I can. He is intending to make a nipple, do some liposuction to the axilla and repair a dog ear on my abdominal wound as well as a mastopexy on the ‘good’ side.
I am prepared for a fight,!
Thanks for all your replies. It does seems I’m not the only one having difficulties with my insurance company. I still don’t really know which way to turn. As well as the recon breast being larger than the normal side I also have lumps located under my arm on that side. The surgeon was concerned about them so I have had scans etc and they have been cleared as non-cancerous. I would ideally like them removed, I’ve been told that as they are on the recon breast side they probably won’t pay for this either. Things are getting so complicated I feel like I’m swimming in treacle!
Thanks for the link to the Financial Ombudsman No1mummy…I think I maybe needing it shortly; either that or visiting my bank manager for a very large loan!
Any other ladies out there considering reconstruction through Private health insurance I would strongly suggest asking what your policy restrictions are. I had spoken to my insurance company before the operation but they did not tell me about any restrictions until after the surgery…by which time it was too late.
My company, APP, paid for the adjustment to my good breast at the same time that my new nipple was constructed. I think there was a lot of delay before my PS got the money with various phone calls but i wasn’t involved. My surgeon did say that if they wouldn’t pay for this second operation, she would do it on NHS and that I wouldn’t have to wait too long.
Kelley
I have just found this Forum. I am disgusted that my sisters have suffered rejection too.
On the positive side, my life has been extended by 18 years following surgery to remove cancerous tumors, and for that I rejoice every day. I had reconstructive surgery, which involved having a tissue expander implanted. The PMI I used at that time covered all the surgery involved with no questions asked. Unfortunately the implant had a shelf life and ruptured in March. My current PMI considers that surgery to deal with this is ‘cosmetic,’ whilst agreeing that It is not for cosmetic reasons??? What??? They claim it is to correct the symmetry, so will not cover it. Interestingly they have not put any of this in writing yet!
I can have it done under the NHS - hopefully in October. However that is not the point! I will continue to fight this, not just for me, but for all my sisters who find themselves in the same position.
Hi englishrose(nice name)Im almost in the same boat as you…my new Diep boob was much too big so I had a revision which meant my PS did some Lipo on it as well as removing a good chunk,that went ok but have more scars now and the breast still doesnt match the other.My Ps and also another male opinion was to not touch my good breast but the Sister said to def have it uplifted.So going with her opinion I asked for an uplift when my nipple is being made.Now Im not sure if I want scarring on my breast as its still as it was untouched just maybe abit droopy! I wish Id travelled to see Elaine sassoon everyone says she is amazing.Not sure if an uplift would look better or worse?
I just wanted to update this thread since my last entry back in August. My health insurance company still refused to pay for the procedure I needed to my reconstructed breast and would not accept responsibility that I had not been fully informed of my policies restriction prior to having the original reconstruction. I needed the tweaking doing to my reconstructed breast to bring it in line with my normal one, so in the end I self-funded the operation to the tune of £1,000! I continued with my complaint to the Financial Ombudsman and guess what……all of a sudden they ‘reviewed’ my case and agreed that they had indeed been irresponsible in not giving me all the information regarding my policy…so have refunded every penny! I took the opportunity to speak to the Ombudsman who was responsibly for handling my case and she said it is becoming increasingly common that Health Insurances only payout after the complaint gets referred to the Ombudsman. I think it’s a disgrace that health insurance companies do not behave in an honourable manner. It was time consuming and upsetting to continually complain however I felt a deep sense of unfairness and wanted justice, which has now been gained. I think my case shows that you really do have to fight hard if you feel you have been treated wrongly by Health Insurance companies! Good luck to anyone else going through a complaints process….as if we aren’t going through enough already!
My reconstructed breast is now finished (tatoo and all) and the result is fantastic.