Transsexual Wins Battle Over Surgery Paymentby
365Gay.com Newscenter Staff
Posted: May 17, 2007 - 7:00 pm ET
(Allentown, Pennsylvania) A 15-month battle with the administrator of a company insurance plan over the cost of sex reassignment surgery has ended in victory for an Ohio transsexual woman.
Electronics engineer Jan Stacy was told by company that its self insured plan covered the surgery, and in 2006 she entered hospital.
But when she later submitted her bills to the plan's administrator, Highmark Blue Shield, it refused to pay.
Stacy went back to the company human resources officer and again was told the company plan included sex reassignment. Nevertheless, Highmark stood firm, refusing to pay.
She then took her case to Equality Advocates, a Pennsylvania organization that provides legal services to the LGBT community.
Even after the initial intervention of Equality Advocates, Highmark continued to insist that it owed no reimbursement to Stacy and extended the policy exclusions to a routine office visit.
The organization and Highmark agreed to an arbitration process to avoid going to court. But even after Highmark finally conceded that Stacy’s surgery was covered by her employer’s current plan, they continued to refuse to pay most of the claim, on the grounds the surgery was performed "out of network", and that the surgeon did not charge the "reasonable and necessary" amount for the procedure.
Equality Advocates persisted and Stacy’s employer intervened forcing Highmark to reverse its position.
Stacy was ultimately awarded $14,097, the bulk of the surgery costs.
"It is appalling how badly Highmark Blue Shield mishandled Ms. Stacy’s claim," said Katie Eyer, Employment Rights Project Attorney at Equality Advocates.
"Their repeated refusal to pay this claim was clearly the result of bias against the transgender community, and demonstrated a willful ignorance of the medical necessity of procedures such as SRS."
Eyer said that transgenders across the country have "systemic" problems dealing with insurance claims. Stacy was fortunate, said Eyer, that her company has a written policy on equality and that it had its own insurance plan which specifically covered transsexuals.
Few other self administered plans or HMOs have such provisions.
Posted: May 17, 2007 - 7:00 pm ET
(Allentown, Pennsylvania) A 15-month battle with the administrator of a company insurance plan over the cost of sex reassignment surgery has ended in victory for an Ohio transsexual woman.
Electronics engineer Jan Stacy was told by company that its self insured plan covered the surgery, and in 2006 she entered hospital.
But when she later submitted her bills to the plan's administrator, Highmark Blue Shield, it refused to pay.
Stacy went back to the company human resources officer and again was told the company plan included sex reassignment. Nevertheless, Highmark stood firm, refusing to pay.
She then took her case to Equality Advocates, a Pennsylvania organization that provides legal services to the LGBT community.
Even after the initial intervention of Equality Advocates, Highmark continued to insist that it owed no reimbursement to Stacy and extended the policy exclusions to a routine office visit.
The organization and Highmark agreed to an arbitration process to avoid going to court. But even after Highmark finally conceded that Stacy’s surgery was covered by her employer’s current plan, they continued to refuse to pay most of the claim, on the grounds the surgery was performed "out of network", and that the surgeon did not charge the "reasonable and necessary" amount for the procedure.
Equality Advocates persisted and Stacy’s employer intervened forcing Highmark to reverse its position.
Stacy was ultimately awarded $14,097, the bulk of the surgery costs.
"It is appalling how badly Highmark Blue Shield mishandled Ms. Stacy’s claim," said Katie Eyer, Employment Rights Project Attorney at Equality Advocates.
"Their repeated refusal to pay this claim was clearly the result of bias against the transgender community, and demonstrated a willful ignorance of the medical necessity of procedures such as SRS."
Eyer said that transgenders across the country have "systemic" problems dealing with insurance claims. Stacy was fortunate, said Eyer, that her company has a written policy on equality and that it had its own insurance plan which specifically covered transsexuals.
Few other self administered plans or HMOs have such provisions.
Labels: 365gay.com newscenter, equality advocates, highmark blue shield, HMOs, jan stacy, ohio, transgender news
posted by Lady Xl @ 8:48 AM
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