Cancer patients requiring reconstructive plastic surgery have been denied or delayed hospital cover by Medibank because the nation’s largest health insurance provider claims it is a “cosmetic” procedure.
Breast cancer survivors requiring nipple reconstructions and treated skin cancer patients and burns victims requiring skin grafts have all had their insurance claims queried by Medibank.
Australian Society of Plastic Surgeons vice president Tony Kane says the insurance provider implemented a new policy in June.
He says dozens of patients have since come forward, saying the insurance provider may not be able to fund their procedure.
“[Medibank] are looking for grey zones that they can exploit because what they’re looking at is the bottom line and trying to control the purse strings,” he told the ABC’s 7.30 program.
Breast cancer survivor Candi Browne required a double mastectomy and elected to have a full reconstruction of her breasts.
But a second stage of her procedure – the tattooing of her reconstructed nipples – was delayed when the hospital admissions department said Medibank was querying the procedure because a new protocol classed it as possibly “cosmetic”.
“I didn’t decide to have a mastectomy and have new breasts for the heck of it,” Ms Browne said.
“I’m just being put back to what I was before.”
After a volley of phone calls back and forth from the hospital to Medibank, Ms Browne’s case was eventually resolved.
She had the procedure and Medibank paid.
“All they succeeded in doing was ending up with a distraught client,” Ms Browne said.
Medibank says it made the decision to challenge proposed plastic surgery procedures after auditing 1,000 hospital procedures it had paid for and discovering 25 per cent were cosmetic.
“We have a duty and an obligation under the Health Insurance Act and to all of our members to ensure that we can do whatever we can not to pay for cosmetic treatment,” Medibank’s chief medical officer, Ian Boyd, told 7.30.
He said he was aware of Ms Browne’s situation and had apologised.
“Early on in the new process – and this has only been going on for six or seven weeks – we did have some communication issues and some governance issues that caused us to make an error in a few cases,” Mr Boyd said.
“If any doctor, hospital or patient out there has any information or any concern that at any time during that process we have unfairly dealt with them or made an error, we’re more than happy to review the case.
“I will do that personally.”
‘Exclusion’ clause exempts patients from coverage
The insurer is also under fire for confusion over so-called exclusion clauses, where patients elect not be covered for plastic surgery in their insurance policy because they thought it referred to cosmetic surgery.
Geoff Drewell has skin cancer and required a skin graft following his treatment but was told his Medibank Private policy excluded plastic surgery.
“It makes me wonder why I pay this money per month to have a situation where all of a sudden I’m out on the street unable to have a skin graft,” he said.
Australian Society of Plastic Surgeons vice president Tony Kane said insurance policies lacked transparency.
“As a result we’re operating on people publicly who have been paying consistently to a private health insurer, at the public’s expense,” he said.
But Mr Boyd said there “was only so much information” Medibank could provide in a website or a product brochure but made an effort to point members to its fund rules.
The insurer’s fund rules do not, however, have a definition for plastic surgery.
Mr Boyd said it would be “well beyond what our members expected” if Medibank was to define “every element of what is a complicated and complex health industry”.
“If a member looks at the information that’s available and can’t find what they require, we recommend that they come back and talk to us,” he said.
Dr Tony Kane says Medibank’s policy change is an attempt to change the doctor-patient relationship.
“What they’ve done is insert themselves into the doctor-patient relationship and said, ‘We don’t care whether the patient thinks they need an operation. We don’t care if the doctor thinks they need an operation. We don’t even care if Medicare thinks it’s a rebateable procedure. We want to make a decision as to whether this surgery should proceed’,” Dr Kane said.
“Our understanding of top hospital cover is that if it’s in the Medicare schedule book, you should be covered for an in-hospital episode. But clearly, that’s not the case now.”
Private Hospitals Association president Michael Roff said Medibank’s decision had caused great distress to patients – delaying their procedures and adding to the hospitals’ administrative burden.
He said some patients had now gone overseas for operations or elected not to have them at all.
Australian Medical Association president Brian Owler warned of an Americanisation of the healthcare system by stealth – moving towards a “managed care” style system where insurers have a say in what procedures doctors do.
But Dr Boyd said Medicare was simply making sure it only paid for genuine medical procedures.
“Moving away from cancer surgery and burns, we have, at the other edge of the spectrum, treatments that are really on the edge around improving someone’s self image or making someone feel better about themselves,” he said.
“I don’t think anyone believes that we should be paying for that.”
Watch 7.30 tonight on ABC for the full report.