The Transgender Legal Defense and Educational Fund (TLDEF) recently won an important case pertaining to gender reassignment surgery being covered by insurance companies. It is not just the initial reassignment surgery that is at issue, but the fact that when an insurance company defines gender reassignment surgery as outside of the parameters of coverage, then much of that person’s health care can be defined as related to or as a consequence of gender reassignment surgery and thus not eligible for coverage. This means that routine health care — mammograms to menopause, heart disease and cancer care — can be related to hormones and disqualified from coverage eligibility. By covering the transition from the beginning, all subsequent healthcare is covered as well. Yeah TLDEF!
Victory! Transgender Woman Wins Insurance Coverage for Sex Reassignment Surgery!!!
We are thrilled to announce that we have resolved a claim on behalf of a transgender woman who had been denied health insurance coverage for sex reassignment surgery. Ida Hammer, a 34-year-old New York City resident, applied for pre-authorization for male-to-female sex reassignment surgery in July 2011. MVP Health Care denied her claim on the grounds that the surgery was “cosmetic” and therefore was not covered under the policy. MVP refused to alter its position and denied two internal appeals, even after TLDEF submitted extensive evidence in support of Ms. Hammer’s claim.
Only after TLDEF threatened to file a lawsuit did MVP reverse its position and agree to cover the doctor-recommended procedure. MVP stated in its letter authorizing the surgery that “the requested surgery is medically necessary.”
“I have been undergoing treatment for gender dysphoria for the past five years. My doctors determined that surgery is the only adequate treatment for my condition,” said Ms. Hammer. “My insurance company should not be second-guessing my doctors. I’m relieved that it is finally treating me fairly and covering the health care I need.”
“The well-established medical and legal consensus is that transgender-related health care is medically necessary care,” said TLDEF executive director Michael Silverman. “This surgery is not designed to improve one’s appearance, but rather to treat a recognized medical condition. Transgender individuals pay the same premiums and simply want the same benefits as anyone else,” he added.
The medical necessity of sex reassignment surgery has been widely recognized in medicine and law. Organizations such as the American Medical Association, the American Psychological Association and the World Professional Association for Transgender Health recognize surgery as medically necessary and support insurance coverage for it. Since the 1970s, numerous state and federal courts have recognized this surgery as non-cosmetic, medically necessary surgery. Even the Internal Revenue Service recognizes transgender-related surgery as medically necessary and tax deductible.
In addition to TLDEF, the legal team representing Ms. Hammer included Robert Goodman, Brandon Burkart, Katherine Kriegman, Ariel Meyerstein and Susan Reagan of Debevoise & Plimpton LLP.