Insurers Wary of Breast Implants

Some women with silicone breast implants are having difficulty obtaining individual health insurance policies, and if the FDA bans the devices in a decision expected next week, they could run into even more coverage problems, insurance industry sources say.

Insurance agent Nancy Wing says insurers including Blue Cross of California and National Casualty are declining to provide individual policies to some women with breast implants. She said the policy denials have occurred during the past year and not only since the FDA imposed a temporary moratorium on the use of the implants last month.

“I don’t really think it’s fair� for these women to be excluded, says Wing, who is president of West Coast Multiple Services and herself had a silicone implant inserted after surgery for breast cancer. She says she and many women she knows have had no health problems with the implants.

Because of the problem obtaining individual coverage, Wing urged women “to take advantage of a group plan when you have it available.� While group plans often do not screen individuals for pre-existing conditions, individual plans often deny or limit coverage to people with health problems such as heart disease, cancer or diabetes.

Women who have had breast cancer often have trouble getting individual insurance for five to 10 years after remission, regardless of whether they have implants, Wing says.

Michael Chee, a spokesman for Blue Cross, says treatment for conditions relating to cosmetic breast implants may be excluded in individual policies, but that denial of coverage would probably happen only if other pre-existing medical conditions were present.

The uncertainty of the insurance situation has added to the stress suffered by women who now do not know whether the implants in their bodies are safe.

“(Insurance) is a real concern. We don’t know what’s going to happen,� says Sharon Green, executive director of Y ME, a support group for breast cancer patients that has been flooded with calls from women worried about the safety of implants.

Most women with implants have not experienced health problems. However, some women experience painful contractions of tissue around the implant, and others charge that silicone leakage from the implants cause immune system disease.

The FDA advisory panel meeting next week may make the temporary ban on silicone implants permanent if it decides that the manufacturers of the product have failed to provide evidence they are safe. However, it is unlikely to deem they are definitely a health hazard because studies on the devices are expected to take several years to complete.

The FDA is now recommending that women who have experienced no problems with their implants not have them removed because of the risk any surgery entails.

Insurance companies are watching the FDA decision carefully.

“Health insurers will be listening very closely when the FDA announces its decision,� says Donald White, spokesman for the Health Insurance Assn. of America. “There is a potential� for the decision to affect coverage, he says.

Most insurance companies do not cover the insertion of breast implants for cosmetic reasons, though they are required by California law to cover reconstructive implants following mastectomies.

Some large insurers and health maintenance organizations including Aetna, Travelers, Maxicare Health Plans and Kaiser Permanente generally cover treatment of complications from implants regardless of whether their initial insertion was covered. However, some plans exclude conditions resulting from elective cosmetic surgery.

Most insurers do not pay for removal of implants unless they rupture or other health problems arise. If the FDA bans the devices, it is unclear whether insurers would pay for removal for women who have not yet experienced problems. Because the scientific evidence about their potential hazards is still unclear, it may be difficult for women to argue that their removal is a medical necessity, experts say.

Insurance companies stress that it is impossible to say what changes would occur in underwriting standards before the FDA decision. Even if the FDA bans the devices, they say it was unlikely that women with insurance now would have their policies terminated because of the use of implants.

Surgery relating to problems with implants “should be covered, but insurance companies will try to weasel out of it if possible,� says Ray Bourhis, a lawyer representing several women trying to get coverage.

However, Chee of Blue Cross says that “if (the implants) are determined to be a health hazard we’d have to develop appropriate benefits. . . . A great deal is hanging on the FDA decision.�

There is a chance that even without insurance coverage, women may get financial help in removing the implants. Officials of Dow Corning, a major manufacturer of silicone implants, have said they are considering paying for removal of the implants in some cases.