I am getting ready to take on Blue Cross for denying my mom's request for teeth. She lost them when they cut out 1/2 her jaw and replaced it with her leg. To do something like this take excellent preperation, so I am asking for any direction to advocacy groups, legal agencies, state assistance ect. She has suffered dearly to live & I feel it is only right to fight with everything to give her back her teeth.

I would start by getting a doctor to sign a letter for the medical reasons why this is necessary. Get copies of all of her medical records then find an attorney specializing in these kinds of cases. You will probably have to sue them.

Annabel,
I don't want to discourage you but I also don't want you to waste the amount of time that I did with Blue Cross/Blue Shield. I have that insurance and I fought them for almost two years. Every doctor I have wrote letters, including my dentist that specializes in cancer patients..........two of these doctors did the "Peer Review", which means they called and spoke with BC/BS themselves. I appealed when they turned me down the first time. They turned me down, of course, again and pointed out that it specifically says in the policy that implants will NOT be covered if loss of teeth is due to disease. There is no fighting that and they wouldn't budge. I am having my implants done this Tuesday and it is to the tune of $52,350, with $1000 covered for the extractions I will have.

Now, on the positive side, I wish you could win the battle with them............please let me know if you do so I can give them a call!!If just one person could apply enough pressure it may work....I simply got tired of fighting them and got to the point where my mouth hurt and I can't eat well at the present time.
Good luck and keep us posted.
Minnie

Annabel,

I often wonder how BC/BS is a "non-profit" company when everything they do seems to be motivated by trying to get out of paying claims. I guess any profits they have are distributed to the higher ups and there is no profit left to report. I'm not too cynical, am I?

I have taken on BC/BS twice, once as a dentist on behalf of a patient and once on behalf of my wife's claim for payment for an osteoporosis drug. I won both times, but it wasn't easy. In the first case when I threatened to sue them and filed a claim in small claims court, I got a call from their president and he said "why didn't you call me, I'm sure we can find a way to settle this". I told him that I was stonewalled by his employees and they would never let me get past the supervisor level. That's how they work. In the second instance, phone calls and letters got me the payment.

Most of the time, they win because their policies are written in such a way that they can opt out of paying. Minnie's case is one that bears this out. Unfortunately, logic never is a factor in their decisions. It's usually what's written in black and white.

So, the first thing that you have to do is read the contract for exclusions. Remember, not all policies are exactly alike, so you mom's may not have the wording that Minnie's does. I would think that if you find similar wording, it's probably not worth your fighting. However, you never know and if you have the time, give it a whirl.

Good luck and please let us know how you make out.

Jerry

anabel. Delta dental would nt pay for my false teeth or pulling my teeth under general anesthesia. Kaiser wouldnt pay for anything about teeth either.

harriet