Woman Wins Battle With Insurance Company for GRS Coverage

[Carolyn Marie]

This is good news, at least for those with this company's insurance plans.

http://www.nydailynews.com/new-york/insurance-pay-sex-change-article-1.1173606

Carolyn Marie

[Guest Jo-88]

Yea I saw this earlier today on facebook, it is just a matter of time before it is universally covered on all major health insurance plans. Just give it a few more years and it will be the norm.

[Cyndee]

Good news indeed, I am really happy for her. The 302.85 I feel is for real, I hope to get some help in our plan too.

C -

[Charlize]

Now i just hope they come to horizon blue cross blue shield. Better yet might be a system that covers all of us instead of all the disparity.

Hugs,

Charlie

[Guest Danielle J]

Hopefully this will mean Tri-care and the VA start covering it

Hugs Danielle

[Drea]

This is great news for Ms.Hammer.

On the other hand this is no different than many other settlements by insurance companies in the past. I don't see anything that says the companies policy changed when it comes to future claims. It doesn't even appear that there is a written settlement, conscent degree or court ruling whatsoever. Nothing that is useful precedent though it certainly doesn't hurt.

Now if there was some sort of written settlement that simply wasn't mentioned, that could very well be noteworthy. Barring that this is no more significant than the many such cases in the past. The fact that this is news serves to highlight how short the community's memory is. How the past gets forgotten and history repeats itself and then is believed to be something new.

Insurance companies routinely deny procedures of significant cost and force claiments to challenge the ruling before eventually relenting and allowing when the doctors insist it is medically necessary. This doesn't seem so different than many of those cases except it relates to SRS, but again maybe there is more to the story that isn't listed.

If anything it should remind people that they can challenge their insurance companies and if they have a good medically necessary claim (not all have good claims) then there is a good chance to prevail. Something that hasn't changed in the past decade or two.

[VickySGV]

This was one of the cases discussed at the Transgender Legal Defense & Education Fund (TLDEF) session at the Southern Comfort Transgender Conference the last week of September. A major element of the case, was the perseverence of the patient and her legal representatives through three levels of appeal within the insurance company. Had the company not accepted the claim, a law suit was prepared to be filed. A crucial elememt to the settlement was that the company felt it would be highly likely to lose a lawsuit and did inform the people at TLDEF of that fact.

Whiie not legal precedent in the sense of a court decision that has been appealed and the appelate decision published, the insurance companies do network and share this type of information between themselves. Insurance companies are involved in the money issues, and there is a growing wealth of information on the cost effectiveness of SRS over multiple hospitalizations for psychiatric care of depression and suicidal ideation, and emergency medical costs for un-successful suicide attempts. The biggest lesson to this one is to be persistent, get competent legal representation which can be from a number of LGBT legal centers or the ACLU which will help our tight budgets greatly with pro bono or slidng scale help.

For those people who wish to short circuit the medical approval route of our GD this case is a lesson in the benefit of credible medical opinion for taking our bodies through SRS. The insurance company was presented with full and adequate evidence of the medical NEED, and not merely the unsupported opinion of the patient. In effect, it took the company's own "supreme court" to un-define SRS as cosmetic surgery for this patient.

I learned a few more details there at SCC, and it was just good fun to me meeting actual legal practitioners who are on our side.

[Drea]

This was one of the cases discussed at the Transgender Legal Defense & Education Fund (TLDEF) session at the Southern Comfort Transgender Conference the last week of September. A major element of the case, was the perseverence of the patient and her legal representatives through three levels of appeal within the insurance company. Had the company not accepted the claim, a law suit was prepared to be filed. A crucial elememt to the settlement was that the company felt it would be highly likely to lose a lawsuit and did inform the people at TLDEF of that fact.

Whiie not legal precedent in the sense of a court decision that has been appealed and the appelate decision published, the insurance companies do network and share this type of information between themselves. Insurance companies are involved in the money issues, and there is a growing wealth of information on the cost effectiveness of SRS over multiple hospitalizations for psychiatric care of depression and suicidal ideation, and emergency medical costs for un-successful suicide attempts. The biggest lesson to this one is to be persistent, get competent legal representation which can be from a number of LGBT legal centers or the ACLU which will help our tight budgets greatly with pro bono or slidng scale help.

For those people who wish to short circuit the medical approval route of our GD this case is a lesson in the benefit of credible medical opinion for taking our bodies through SRS. The insurance company was presented with full and adequate evidence of the medical NEED, and not merely the unsupported opinion of the patient. In effect, it took the company's own "supreme court" to un-define SRS as cosmetic surgery for this patient.

I learned a few more details there at SCC, and it was just good fun to me meeting actual legal practitioners who are on our side.

Basically sumarizing what has been the circumstnces for the better part of the past 20 years. As far as the insurance companies netowrking, again not new and such has been shared.

People with a good claim that it is medically necessarily have been successful plenty of times in the past. If I recall correctly, my therapist had 4 clients herself that successfully challenged insurance companies to get their surgeries paid and that was over a decade ago.

I agree, the do it yourself-ers will have difficulty as well as those for whom it may not be medically necessary will have a poor case for challening an insurance company denial.

[Guest KimberlyF]

I've heard these stories for many many years too. If you get rejected, don't take the first no.

Like this bit from TS Roadmap says:

' Often times a 50 to 75 dollar letter from an attorney to an insurance company can get the money flowing to the patient.'

http://www.tsroadmap.com/reality/insurance.html

Also who wrote this poorly written article? What is the yearly care after surgery? A physical everyone should have? Most have their HRT lowered post-op so it costs less day to day after.

[Guest Rawrsome]

Its quite a reassuring thought to see the world beginning to accept people for who they are, and recognize their needs...even if it takes the threat of a lawsuit to make them see it.