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If HMO Doesn't Inform Me of a Hernia for 4 Years Are They Required to Pay for Tummy Tuck?

I went to Kaiser in 2006 for an ctscan due to pain in my abdominal area. I returned in 2010 and demanded another ctscan. I was then informed that I had an abdominal hernia since 2006 which grew. The physicians ( a total of 3) admitted in the initial doctor's notes that he never informed me. I now have a fatty lump and will soon have surgery. Can I make Kaiser perform/pay for my tummy tuck surgery. How will I ever have better abdominal structure/muscles now. I don't want to have to pay for it.

Doctor Answers (9)

Tummy tuck is a cosmetic operation

+1

I think Dr. Cavali hit the nail on the head.  A tummy tuck or an abdominoplasty is a cosmetic operation.  If you wish to discuss your concerns with the plan administrator and try to get them to pay for it, then more power to you.  I wish you the best of luck, but realize that this is no different than you telling Kaiser that since they missed your hernia they should pay for your new wardrobe. 

Columbus Plastic Surgeon
5.0 out of 5 stars 4 reviews

Missed abdominal hernia with progression of disease

+1

I would approach the plan administrator or appeal to the medical director with an appeal letter discussing your concerns and requests. This could take some time but I would pursue this until you had a satisfactory answer.

Web reference: http://www.bodysculptor.com/body-surgery-chicago/tummy-tuck/

Chicago Plastic Surgeon
5.0 out of 5 stars 39 reviews

Kaiser Permanente payment for "tummy tuck"

+1

Read the contract between you and Kaiser Permanente thoroughly to determine your rights and responsibilities, and armed with this information, approach Kaiser administration or write them with your request.

Web reference: http://www.feelbeautiful.com/body/tummy-tuck-san-diego/

San Diego Plastic Surgeon
5.0 out of 5 stars 36 reviews

Wow

+1

In a world where it's "fair" for you to get a free tummy tuck in exchange for a "missed" hernia diagnosis, then I should be entitled to a brand new Maserati when my Camry gets an oil leak that's not fixed the first time.

A tummy tuck does not fix a hernia.  A tummy tuck is cosmetic and not covered by insurance.  Your hernia repair should be covered by insurance, so you might pursue that.

Atlanta Plastic Surgeon
4.5 out of 5 stars 16 reviews

Tummy Tuck surgery is not required to fix a hernia

+1

I'm going to drop the usual diplomacy for a moment ask the following rhetorical question: why on Earth would you feel entitled do a free cosmetic operation (tummy tuck) simply because your HMO 'missed' you abdominal hernia? This line of reasoning behind this question is baffling on so many levels. 

First of all- an abdominal hernia is not repaired using an abdominoplasty approach. Hernias can be fixed laparoscopically, or via an 'open' approach. If an abdominoplasty is done in combination with hernia repair, then only small umbilical or ventral hernias should be repaired.

Secondly, an abdominoplasty addresses abdominal wall laxity, rectus diastasis (not a hernia), excess skin and abdominal fat.  

A tummy tuck is a cosmetic operation. You pay for it. The hernia repair is a reconstructive operation. The insurance company pays, in part, for it.

Seattle Plastic Surgeon
4.5 out of 5 stars 32 reviews

If HMO Doesn't Inform Me of a Hernia for 4 Years Are They Required to Pay for Tummy Tuck

+1

Funny Dr Aldea, and he is right!. You should realize even if the HMO approved the hernia repair they would only authorize the direct incision approach NOT a tummy tuck incision. So you will have to pay for that part of the tummy tuck or cosmetic portion NO MATTER what you feel. Sorry. I believe you but insurance companies DO NOT CARE!

Miami Plastic Surgeon
4.5 out of 5 stars 56 reviews

NO

+1

The hernia can be repaired without doing a tummy tuck. A tummy tuck is a cosmetic operation and usually not covered by any insurance.

New York Plastic Surgeon
4.0 out of 5 stars 8 reviews

Keiser HMO Doesn't Inform Me of a Hernia for 4 Years Are They Required to Pay for Tummy Tuck?

+1

Regarding:"If HMO Doesn't Inform Me of a Hernia for 4 Years Are They Required to Pay for Tummy Tuck?
I went to Kaiser in 2006 for an ctscan due to pain in my abdominal area. I returned in 2010 and demanded another ctscan. I was then informed that I had an abdominal hernia since 2006 which grew. The physicians ( a total of 3) admitted in the initial doctor's notes that he never informed me. I now have a fatty lump and will soon have surgery. Can I make Kaiser perform/pay for my tummy tuck surgery. How will I ever have better abdominal structure/muscles now. I don't want to have to pay for it
."

This is a medical website not a legal fishing "Do I have a case, Doc?" site. For legal advice on WHO should have done WHAT WHEN you would be better served seeing a legal opinion.

As regards your condition, you are making a common error in asserting that a Tummy Tuck is THE treatment for a ventral or umbilical hernia - It is not.

Obviously, none of the doctors taking the time to respond to your question were in the room in 2006 when you were examined or when this was repeated recently. We can only respond based on our experience with many cases similar to yours which may or may not be accurate.

You clearly have the proof that you had a ventral hernia back in 2006. However, having an abdominal hernia is not always a reason to operate. If the hernia does not hurt, interfere with your activities or is caught in the opening (INCARCERATED) or is in danger of being caught - there is no reason to operate on it. If it requires an operation - the procedure would be a Ventral Hernia Repair NOT a Tummy tuck.  Now that the hernia IS much larger and painful, the operation is STILL A Ventral Hernia repair (which depending on your size and the size of the hernia may be done through small incisions.

I cannot speak as to Keiser's real or imagined ventral hernia repair guidelines in 2006 or 2010 but I can assure you that NO commercial insurance would pay for a Tummy Tuck (which is a cosmetic operation) instead of a Ventral Hernia repair.

A Tummy Tuck is a MUCH bigger operation than a Ventral Hernia repair in which the naturally split muscles are tightened and excess skin is removed. It DOES allow for the visualization and repair of ventral hernias but this takes extra effort.

If you change your mind, you COULD pay for the Tummy Tuck and have either the general surgeon or Plastic surgeon, if Keiser permits, do the ventral hernia repair portion only as "insurance based", while you pay for the rest as is only fair.

Hope this helped.

Dr. Peter Aldea

Memphis Plastic Surgeon
5.0 out of 5 stars 52 reviews

Tummy Tuck and Hernia Repair

+1

Basically, the hernia and tummy tuck are two separate procedures.  Many times, I will repair a hernia at the same time as the tummy tuck.  However, the hernia repair is reconstructive and the tummy tuck is cosmetic.  So, I highly doubt that your insurance company will agree to pay for the cosmetic portion.  Good luck.

Web reference: http://www.ShaferPlasticSurgery.com

New York Plastic Surgeon
5.0 out of 5 stars 52 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.