Breast reconstruction a cosmetic procedure, insurers say

By Jane Phare

Distressed breast cancer patients are furious to discover insurers will pay only a fraction of breast reconstruction costs because the procedure is considered non-essential

Kylie Richardson was diagnosed with breast cancer at 27. Photo / Martin Hunter
Kylie Richardson was diagnosed with breast cancer at 27. Photo / Martin Hunter

Moana Berry thought this year would bring a fresh start after a gruelling battle with breast cancer.

Instead, the single mother of two has been "devastated" by an $11,500 debt she can't pay, money her insurance company refuses to refund for her breast reconstruction.

Berry was diagnosed with breast cancer in June last year and underwent a lumpectomy and chemotherapy. Then, just before Christmas, she learned she needed a full mastectomy and had an operation, in which body tissue, fat and muscle from her abdomen were used to rebuild her breast.

After the operation, the 42-year-old Hamiltonian had to resign from her job because of ill health. This year, she thought, could only improve. "I had a spring in my step. I was over it, healing and now this. It has knocked the wind out of me."

"This" is the discovery that Sovereign Insurance, to whom she has been paying health insurance premiums for 10 years, will not cover much of the surgery.

Berry owes her plastic surgeon $11,500, an amount she thought her Sovereign Total Care policy would cover. "I feel really let down."

Now, two months after surgery, and undergoing radiation, she is desperately searching for a job to pay the bill.

Berry won't be getting nipple reconstruction or tattooing because she can't afford it. She has had to stop physiotherapy. And she is dreading her post-operative check with her surgeon next month because of the debt. "It puts me in a very embarrassing situation."

Sovereign's popular Total Care Policy covers most surgical procedures up to a value of $100,000, but applies a far lower $15,000 limit to breast reconstruction - and it's not alone. Unimed's Major Surgical Plan sets the same limit.

The insurers argue that although the mastectomy is medically necessary, anything after that is cosmetic.

Breasts are a frippery, essentially.

The problem is $15,000 doesn't buy much in terms of reconstruction. One surgeon quoted $44,000 for a Tram flap procedure, $35,000 for a two-stage implant, $25,000 for a one-stage and $6,000 for nipple reconstruction.

Before her surgery in December, Berry says an insurance representative assured her she had $100,000 surgical cover and that everything was "fine". The $15,000 restriction was not mentioned. The surgeon sent his estimate to Sovereign so Berry never saw it.

When her prior-approval came through shortly after, Berry noticed the $15,000 limit but, because of the phone conversation with Sovereign, she assumed it did not apply.

She went into surgery confident she was covered. It was only when Berry submitted her medical expenses for payment that she realised she was in trouble. The $15,000 was swallowed up, leaving $11,500 of her surgeon's bill unpaid.

"I don't think it's fair," she says.

Women go through a very traumatic period and they have to come to grips with a huge amount when they go through a mastectomy. It is not unusual for women to wait for reconstruction and those women need to be aware of what their insurance policy covers.

- Karen Stevens, Insurance and Savings Ombudsman


One in seven New Zealand women will be afflicted by breast cancer, but they do not have the same legal protections as overseas. In the 1990s, American surgeon Christine Horner ran a five-year campaign to require insurance companies to pay for breast reconstruction after mastectomy. The bill became federal law in 1998 under President Bill Clinton. That's not the case in this country.

One Auckland woman discovered just four days before her mastectomy that her top-end insurance policy did not cover her fully for breast reconstruction, despite having a $100,000 allowance for each surgical procedure. A $15,000 cap meant the 61-year-old, who wants to be known only as Ann, had to have a one-step mastectomy and implant rebuild, which she did not want.

Three months later, Ann has been left traumatised and in severe pain, and is considering booking into the public system to have the breast removed altogether. She is warning other women: check your policy.

Aware of other cases where women have been caught out by similar polices, New Zealand Breast Cancer Foundation chief executive Van Henderson is trying to find out which insurance companies have targeted breast reconstruction and why.

And Insurance and Savings Ombudsman Karen Stevens, whose office has received numerous complaints about breast reconstruction issues, warns women to read their policies carefully and take note of any changes.

She says the most common complaint is whether reconstruction at a later stage is covered, or considered cosmetic.

"Women go through a very traumatic period and they have to come to grips with a huge amount when they go through a mastectomy," she says. "It is not unusual for women to wait for reconstruction and those women need to be aware of what their insurance policy covers."

One insurance claims officer told a woman facing a mastectomy that her company considered a woman could lead a perfectly healthy life without a breast.

Breast surgeons and Henderson argue that for many women breast reconstruction is a vital part of recovering from cancer. "It's about feeling whole, feeling like a woman again."

That was not an option for Ann under her Sovereign Insurance Major Care Policy, for which she pays $313 a month.

The week before surgery, Ann discussed various options for reconstruction with her surgeons, including taking tissue from her back to rebuild the breast, or using a temporary expander to stretch the breast skin and muscle gradually before a second operation to insert a permanent implant.

Those options disappeared when Ann discovered the $15,000 cap. There was only enough money for a one-stage reconstruction, and not enough for nipple reconstruction.

Now the stress of the insurance restriction and the pain of the one-step implant has left her anxious, tearful and sleep deprived.

Breast surgeons say there are cases where a one-operation mastectomy and implant is suitable but most women need the two-stage implant, which stretches the skin and muscle more slowly. Many want to use their own body tissue, avoiding implants.

Plastic surgeon Stephen Mills, chairman of the Breast Cancer Foundation's medical advisory committee, says he was "astounded" to hear from a patient that her Sovereign policy covered only $15,000.

"The same day I was operating, I heard of two other colleagues who had the same thing happen to their Sovereign patients. Their patients had to have their reconstruction curtailed to fit with the money. It makes for an incredibly stressful situation."

Mills says itis wrong to categorise breast reconstruction as standard cosmetic surgery. "It's incredibly denigrating to women. To dismiss it as just being cosmetic is, I think, really insulting."

Auckland surgeon Alex Ng says reconstruction is a medically appropriate procedure to assist with healing and rehabilitation. "I think it quite important that the option not be dictated by restrictive financial considerations."


Sovereign spokesman Chris Lamers says the $15,000 cap was introduced as an "enhancement" to its policies several years ago. Sovereign paid out fully for breast reconstruction before that, but not in all cases.

The cap brings "clarity" for the customer and is seen as a benefit rather than a restriction. Breast reconstruction slips between general and cosmetic surgery, he says. "Now we're making it clear."

Sovereign considered $15,000 to be an adequate amount for reconstruction when the cap was introduced, Lamers says, but is now reviewing that amount. He says the company is not discriminating against women with breast cancer: men with prostate cancer also have a $15,000 cap on penile implants.

The Ministry of Health says reconstruction is an important means of enhancing body image and self-confidence after mastectomy, but some DHBs have long waiting lists.

Christchurch web designer Kylie Richardson was 27 when she was diagnosed with breast cancer. It was the start of a stressful three years, living in a "broken house" after the earthquake, struggling with EQC and undergoing treatment.

Her breast surgeon advised her to delay reconstruction because of the damaging effect radiation can have. Before chemotherapy began, Richardson and her husband Todd did an IVF cycle in case her fertility was affected by the drugs. They have five frozen embryos still waiting to be implanted.

Then came a wait of 2 years for a reconstruction, using skin and fat from the stomach, while wearing a "chicken fillet" prosthesis.

In the private sector, the procedure costs more than $45,000. Under some insurance policies, Richardson would not have had that option. As it was, she had to wait. "It's a long time not to be able to shop for bras and bikinis and low-cut tops," says Richardson, now 31. "Some people think it is just cosmetic but it affects the way you feel about yourself."


What they cover

Unimed - No limitation on breast reconstruction if done at the same time as mastectomy . $15,000 limitation (payable once only) on delayed reconstruction, including nipple reconstruction and tattooing. No time limit if first diagnosis is since May 1, 2005. Access to specialists after treatment varies depending on the plan. High-end plans include no restriction or time limit; other policies stipulate specialists are covered six months before and six months after treatment.


nib (formerly Tower) - No limitation on breast reconstruction (less policy excess), except for policies that do not cover cancer. No time limit on reconstruction. Will cover nipple reconstruction and tattooing. Will cover a specialist appointment and relevant procedures, such as a scan, for the next five years.

Southern Cross - No limitation on breast reconstruction surgery on high- end policies, up to $100,000 cover. Includes nipple reconstruction and areolar tattooing. Lower end "shared care" policies have surgical maximums of less than $10,000 for each procedure. Reconstructive surgery must be completed within two years.

Sovereign - $15,000 limitation on breast reconstruction surgery, for each breast. Nipple reconstruction and tattooing is included in the $15,000. No time limit on reconstruction. Specialist appointments covered six months before and after surgery, unless policy includes on-going specialist and tests cover.


Dianne Mayson's insurer classified replacing her faulty implant as cosmetic surgery. Photo / Getty Images
Dianne Mayson's insurer classified replacing her faulty implant as cosmetic surgery. Photo / Getty Images

Years of pain and worry after company's refusal

Solo mother-of-three Dianne Mayson spent years in agony and on morphine, desperately trying to find a way to have her breast implant removed.

Diagnosed with breast cancer in late 2009, Mayson had a mastectomy and implant reconstruction, a procedure that was covered fully by her Sovereign Insurance Absolute Health policy.

But after six weeks of radiation, Mayson realised something was wrong. The implant had become hard and was riding up. It began to look obvious through clothing but worse, the increasing pain became unbearable as the implant began protruding from her chest.

"You could see the right side of the implant through the skin. I couldn't breathe, I couldn't sleep, it was affecting everything I did."

Mayson, 50, from Orewa, had to resign from her teaching job a year after her diagnosis because of health issues. She worried about the effect on two of her children still at home, Amelia, now 20, and Harry, now 16. Mayson didn't tell her children she had cancer until two days before surgery because Amelia was sitting NCEA exams.

As the pain and breathing problems increased, Mayson's breast surgeon and oncologist told her the implant had to be replaced as soon as possible. That's when her troubles started. Mayson discovered Sovereign wouldn't pay to have the implant replaced, classing it as cosmetic.

"The fact that this implant had to be removed for medical reasons didn't matter to them at all."

Surviving on morphine, Mayson began a year-long battle, backed by her doctors, to find a way out. She was told it would be highly unlikely that the public system would replace her implant because of the long waiting lists of women waiting for reconstruction.

The owners of an inner-city pub, hearing of her plight, offered to run a fundraising evening for her.

Finally her doctors persuaded ACC to pay for the removal and reconstruction under a medical misadventure claim. She had surgery last October.

But Mayson is angry that an insurance policy she paid into for 12 years let her down when she most needed it.

"I lost more sleep over how I would pay the bills than over the cancer itself," she says.


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