Insurance company keeps customer waiting on decision to pay for cosmetic surgery after car accident

DENVER - Should a car insurance pay for cosmetic surgery after a crash? Following a car crash in June, a woman is still waiting for her insurance company's ruling on whether it will pay to repair a ruptured breast implant.

The woman, who asked 7NEWS to conceal her identity, told CALL7 investigator Theresa Marchetta that the ruptured implant causes her to feel "broken" and like "less of a person."

"The accident was bad enough and later on, a few months later, to look in the mirror and part of you is gone. It’s like, this is something that I should be able to have fixed," she told Marchetta.

It took until Jan. 1, nearly six months after her accident, for the insurance company to acknowledge that the policy had $5,000 dollars in Medical Payment coverage that may be used for "reasonable and necessary" medical treatments caused by the accident.

However, the company has not confirmed that the money can be used for reconstructive breast augmentation. They are telling her to have the surgery first, then submit receipts for reimbursement.

Vincent Plymell, communications manager for the Department of Regulatory Agencies' Division of Insurance (DORA), confirmed there is nothing in state law or in division of insurance regulations that addresses cosmetic surgery coverage. However he explained, "state law does say that if someone suffers an injury, sickness or disease as a result of the use or operation of a vehicle that the medical care should be covered."

"Her plastic surgery has nothing to do with this case," said personal injury attorney Michael Sawaya. "She has a part of her body that is now deformed. If she decided to have her body look a certain way and they’ve deformed it, this is a medical expense."

Insurance companies generally reimburse medical costs after receiving receipts of service. However, Sawaya told Marchetta that it would be reasonable for the insurance company to tell the woman whether or not they will cover the surgery before she incurs the costs.

"She told this insurance company who the doctor is," Sawaya said. "The doctor has sent a statement that this is necessary. I think all they have to say is yes you have to incur this, and we'll pay up to $5,000 dollars. What is wrong with that? What is unreasonable about that?"

Plymell agreed, saying that all Coloradans are entitled to ask questions of their insurance carrier. They should be able to find out the way things are going to work, what is in their coverage, and how their claim will be processed.

The lengthy experience has been emotionally painful and has caused the woman to feel constantly judged.

She told Marchetta, "part of being a woman is to look in the mirror and see a whole person."

If you have a question about your insurance policy, contact your provider first. DORA's Consumer Affairs is another resource for Coloradans with question regarding their insurance. They can be contacted 303-894-7490 or if outside the Denver Metro area, 1-800-930-3745. Information is also available online at: www.dora.colorado.gov/insurance