Very Long Story

As of today, I do not even have an approval for my orthognathic surgery. Very, very long story. But tomorrow (or latest - the day after) I am "supposed" to have an "answer." I know - pretty vague. You see, my situation has been a WAY long time coming. I remember at around 12 years old in my first set of braces, the orthodontist was leaning over my mouth pointing and explaining to my dad that I would eventually need surgery to correct my open bite. What?! Now I'm anxious. Two reasons: 1) surgery?! 2) even then I was obsessed with having good teeth (blame my mother), and I was now convinced that something was wrong and it HAD to be corrected. (Note: I am also a very big worrier). But a skeletal jaw "deformity?!" I'm deformed?! How would you feel?

Well, my dad scoffed at the idea. Yep - "scoffed." That's the only way I can describe it. I only ever witnessed this disgusted-at-the-thought reaction when money (his) might be involved. I didn't have health insurance. And he certainly was not going to pay out of pocket. I don't know if he was questioning the necessity or he thought the orthodontist had an ulterior motive - making a few extra bucks, but my dad was acting like he had just been insulted by a stranger. These damn braces were already costing him an arm and a leg, right? Needless to say, the surgery never happened and my dad never brought it up again. Throughout the next four years, I had several dentists (of whom a friend's family consisted entirely of) talk to me about what could be done for an open bite. They could always grind down some of the back teeth, pull a few, maybe crown a few to fill in the space between the upper and lower teeth that did not make contact. (Another note: if your upper and lower teeth don't make contact you can't chew food very well and you choke all the time - no fun). But, I was absolutely not willing to compromise my real teeth. I felt very lucky to have my own. My mom would always talk about how important it was to take care of them so I didn't have to ever get dentures. So, no pulling or grinding for me. I brushed and flossed and cared way to much about these babies to go and grind them up. It needed to be done right. But later, after moving states and having another orthodontist reiterate the same suggestion for jaw surgery (along with wisdom teeth and tonsils needing to go), the braces came off without the procedure (again, issue of no health insurance), but my teeth "looked" perfect. The braces had really seemed to close up the front pretty well and for a while I forgot about the whole surgery issue and just relished these gorgeous, white gems showing off for my senior year.

Fast forward a few years. Inevitably if you have this problem, the teeth will go back. Back to the open bite after all that effort. I was devastated. Chewing, eating, breathing, and pain all became a problem again. At 19 I sure wasn't making enough money to go out and pay for surgery so I (blindly) went and got my first ever health insurance policy. I did this before going to a surgeon because I was afraid of being excluded for a pre-existing condition. I was so worried about that part that I just had it in my mind that I had to pick a plan, submit for orthognathic surgery and then hope I got lucky (anyone like gambling?) Well, of course there's that waiting period. Blah blah blah. Broke as I was at that age with only a part time job, I made payments on that high premium every month and held my breath. Finally when I was able to even start submitting anything, I went to the surgeon. He submitted for the surgery. And they denied the claim. Devastated. Again. I didn't know what I was doing or what to do - the whole insurance thing was intimidating as it was. I can't remember if I tried to appeal or if I just gave up. But eventually I stopped paying for that worthless insurance and let go of my dream for 6 more years.

After college, I move to LA, and get a job with moderate pay, but great benefits (including health insurance). For a while I didn't even think about the surgery because I just tried to bury those hopes so that I wouldn't be disappointed again. But then, I go to the dentist for a regular check-up, he mentions my open bite, I say I know, he suggests an orthodontist, ugh, another one?, and I call him up. I go to the orthodontist who says to go to the oral surgeon who checks my coverage. And ... its a covered freakin' benefit! Oh. My. Gosh. I am practically hyperventilating. I know this won't make sense unless you've been there, but for those of us that have lived with teeth/jaw problems which equal chewing, choking, breathing, pain and speech problems, you can imagine my excitement. Now all I have to do is come up with $4,000+ for braces again (those fancy new clear ones are an extra $1,000). Ugh.

Whatever. It's worth it. I get the braces again. I am SO not excited to be an adult brace-face, but I just cannot pass up the opportunity to finally get the surgery I need to correct this problem permanently. It's been exactly 19 months in braces now and my teeth are in perfect (read: uncomfortable) position for surgery. The new problem is this. Today is July 1st, 2008. In December 2007 my surgeon submitted the authorization for the procedure and it was approved, no problem. So happy. January 2008, less than a month later and before I actually get the surgery however, my employer decides to change health insurance plans. But not to some familiar, comparable plan. To a self-funded Employee Benefit Trust. Tell me if you've ever even heard of this. The company, instead of paying a set premium each year to an insurance carrier, covers all medical costs themselves out of this newly created Trust. Good for them - they only pay when people use their benefits and this saves them A LOT of money. I can appreciate that. Thing is - because of this, the Plan is only, I repeat ONLY, subject to Federal Law (ERISA). Not state laws. This is a whole different set of rules. I re-submit to the new Plan for my (previously approved) procedure, scheduled for March 29th, 2008 and I am DENIED. Then, after appeal, I am DENIED AGAIN, based on an exclusion for the "treatment of TMJ Disorder Syndrome." What the hell?! Did they overlook that dreadful diagnosis of my "Skeletal Jaw Deformity?!" Are they idiots? Are they calling my doctor a liar? Well, worst part is this: once you have exhausted all internal processes (one appeal = exhaustion) you're (only) right is to bring suit in Federal court. That is where I'm now at 6 months since I have been waiting to have this surgery, with all orthodontict progress stalled indefinitely. I feel trapped.

But, with new pissed-off motivation I have been in our HR Director's office everday, emailing, calling, having other people call. And apparently they are "trying" to work it out. There's all these technicalities and liabilities and procedures that have to be figured out because of the subjective nature of our fabulous freakin' Plan.

So, I sit and wait and hold my breath and get sick to my stomach in anticipation. I "put my foot down" today though and said I could not wait any longer than THIS Thursday (before the 4th of July holiday) to have confirmation in writing if they're going to turnover the 2nd denial. I really don't want to (but will) exercise my one available right otherwise. (Of course I didn't say that out loud).

So, here I am. Waiting.