Insurance Confusion — Breast Cancer

We have all seen the catchy T-shirts for the Susan B. Komen walks “Protect the Tatas.”  Few adult diseases have received as much fund-raising attention as Breast Cancer, and for good reason.

Did you know that according to Florida law, your insurer must pay for reconstructive surgery if the policy provides coverage for the mastectomy?

Florida Statutes section 627.7417, much like the Women’s Health and Cancer Rights Act, sets forth:

“Any group, blanket, or franchise accident or health insurance policy that provides coverage for mastectomies must also provide coverage for prosthetic devices and breast reconstructive surgery incident to the mastectomy. The insurer may charge an appropriate additional premium for the coverage required by this subsection”  A policy that covers mastectomy must also cover the entire hospital stay.

Am I missing something?  If breast cancer is important enough to mandate certain coverage, shouldn’t all care related to breast cancer be covered and not just the nip and tuck?

We can leave for another day whether insurance companies should have to cover breast cancer or must cover anything.  By in large, the legislature has already made that decision by passing the law they did.  The statute does not require reconstructive surgery for mastectomies or breast disfigurement caused by any other disease but cancer.  So, breast cancer is something different—something which required these protections:  insurance companies must pay for screenings, for hospital stays long enough to recover from mastectomy, and they must pay for reconstructive surgeries.

Breast cancer predominantly effects women and for decades, health care policy and research reflected a male-centered agenda—and without going into how or why that happened, it was a good thing that the country and health care professionals stood up and noticed breast cancer—which, according to the Centers for Disease Control and Protection, the CDC, remains “the most common cancer in women, no matter your race or ethnicity.” For more information and statistics, go here.

And the statistics are telling.  Not only because they demonstrate the need for research and attention to this disease—it shows how that research is performed.  It’s all about genetics.  We track the risk of cancer based on genetics because that’s what the disease is—a genetic mutation.  A huge part of understanding the risk for cancer is in seeing what makes up your family tree.

Risk is also how insurance companies figure out how much our insurance should cost.  But they are barred from using ethnicity to do that and for VERY GOOD REASON. That’s a slippery slope to bias.  So there goes their rubric for rating risk of breast cancer.  They can’t deny coverage or refuse to renew based on whether you have a family tree that risks bearing breast cancer, because they can’t base their decision on your family tree.

But not if mastectomy coverage is elective. Then the ball is in your court.  I mean, maybe you want to exclude out mastectomy if you know you are at no or little risk of having it.  But then, isn’t that exactly counter to how insurance is supposed to work?  If we leave the ball in the consumer court, where we can all calculate our own risk and pay for our own risk, aren’t we just treating insurance like a savings account?  And if we are saying something is important enough about breast cancer to require screening and to require reconstruction, why aren’t we covering all the prophylactic and treatment measures?

If your policy covers cancer (does not exclude cancer), a mastectomy is probably covered.  But curing cancer that is detectable as a lump is not treating breast cancer.  Finally, well not finally, but increasingly, we are getting the research into breast cancer that will make a difference.  Proactive treatment. Just last year, the National Institute of Health announced the first study on African American women and breast cancer.  And all the research is pointing to one thing: preventing the risks we encounter.  And there is the complication:  a doctor can decide you should have a mastectomy before the cancer is present, and in that scenario, it is not clear that your complete cancer policy will cover it. Women have been denied coverage for dual mastectomies when the cancer has only existed in one breast and not the other—even if the doctor is recommending the double mastectomy.

Increasingly, we are learning more about women’s health and being asked to make some really, tough choices. Sort of.  And whatever you decide to do, well the insurance company whose premiums you’ve been paying should be there to make sure you look ok after.