Colorado transgender woman challenges Aetna's denial of coverage for surgery

http://www.denverpost.com/breakingnews/ci_28547845/colorado-transgender-woman-challenges-aetnas-denial-coverage-surgery?source=rss

By Electra Draper
The Denver Post
Posted:   07/28/2015 04:30:00 AM MDT

A Colorado transgender woman's insurance company has denied her coverage for gender reassignment surgery she says is medically necessary and should be ensured by state law and policy.

Ashlyn Trider, 33, said Aetna Life Insurance Company's refusal to pay for gender reassignment surgery prescribed by her doctor violates Colorado law. The Transgender Legal Defense Fund & Education Fund has demanded Aetna reverse its decision.
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It will be interesting to see how this plays out. I believe, and the story seems to confirm that Colorado requires health insurance policies to be trans-inclusive. Aetna claims that Ashlyn's policy has an exclusion for SRS, so it would seem that Aetna should not have been allowed to sell the policy in Colorado if there is the trans-exclusionary clause. I'm not a lawyer and this is just MHO.

Also see follow up below.

Quote from: traci_k on July 28, 2015, 06:45:24 AM
It will be interesting to see how this plays out. I believe, and the story seems to confirm that Colorado requires health insurance policies to be trans-inclusive. Aetna claims that Ashlyn's policy has an exclusion for SRS, so it would seem that Aetna should not have been allowed to sell the policy in Colorado if there is the trans-exclusionary clause. I'm not a lawyer and this is just MHO.

I'd be surprised if this wins. The anti-discrimination clause just says that they can't deny you SRS because you're transgender. I.e. they can't cover it for non-trans people but deny it to trans people. That's not what's happening. They're denying it to everyone. So I don't think this suit succeeds as an anti-discrimination suit.

As to whether policies can exclude medically necessary coverage is an independent question, and is not addressed by the article.

Follow up

TLDEF Applauds Colorado Decision Banning Transgender Health Care Discrimination

http://www.transgenderlegal.org/headline_show.php?id=405

Transgender Legal Defense and Education Fund


TLDEF applauds the release of a bulletin by the Colorado Division of Insurance which bans health insurance discrimination against transgender Coloradans.  The bulletin mandates that transgender Coloradans be afforded the same care and treatment as all Coloradans under their health insurance plans.  It bars the common practice of excluding medically necessary care prescribed for the treatment of gender dysphoria and requires private health insurance companies to cover medically necessary care for transgender Coloradans on the same terms that they cover all care.

"Transgender people pay the same premiums and just want the same health care that everyone else receives," said TLDEF staff attorney Noah Lewis.  "Transgender Coloradans routinely saw their medically necessary care singled out for exclusion by insurance companies even when the treatments they sought were covered for people who aren't transgender," he added.  "These exclusions were discriminatory and damaged the health of transgender Coloradans.  The Colorado Division of Insurance has now declared that this must end.

The medical necessity of transgender health care, including hormone therapy and 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 these treatments as medically necessary and support insurance coverage for them."
...More...
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From the looks of it, the only out Aetna has is if there is a transgender exclusionary clause in her policy, when it was written and time frame. From the looks of it though transgender exclusion is no longer allowed.

I have Aetna.   I'm keeping my fingers crossed that they don't cross me.  I also know plenty of lawyers who could take them down and probably make them beg to pay for my boob job as well.

Jill,

From the above referenced post byTLDEF - California mandates Transgender Health Services so you shouldn't have an issue.

Colorado joins California, Oregon, and Washington, DC in prohibiting discrimination against transgender policyholders.

Lucky Girl.

The devil is, as usual, in the lawyerly details.  I am appealing my denial of care in Oregon where we hoped the law would mandate comprehensive care.  The insurance industry has enough exclusionary riders to be changing slowly and with resistance.  We had hoped some big names like Aetna, Blue Cross and Kaiser would demonstrate real leadership but it is clear to me that enforcement by the state or feds is going to be necessary.  While most are now providing HRT, GCS/SRS is policy specific with only federal employers, the state OHP and a few big employers getting on board so far.

Work to be done for justice and equity.

Quote from: Tessa James on July 28, 2015, 03:24:24 PM
The devil is, as usual, in the lawyerly details.  I am appealing my denial of care in Oregon where we hoped the law would mandate comprehensive care.  The insurance industry has enough exclusionary riders to be changing slowly and with resistance.  We had hoped some big names like Aetna, Blue Cross and Kaiser would demonstrate real leadership but it is clear to me that enforcement by the state or feds is going to be necessary.  While most are now providing HRT, GCS/SRS is policy specific with only federal employers, the state OHP and a few big employers getting on board so far.

Work to be done for justice and equity.

I assume the flood gates of coverage will not open until the insurers find that covering us without question is less expensive than fighting us in court.  I'm guessing that it's business as usual (denial) until they get a nudge from a judge and significant punitive damages for illegal claim denials become the norm. 

Quote from: Jill F on July 28, 2015, 03:33:58 PM
I assume the flood gates of coverage will not open until the insurers find that covering us without question is less expensive than fighting us in court.  I'm guessing that it's business as usual (denial) until they get a nudge from a judge and significant punitive damages for illegal claim denials become the norm. 

You are sadly correct IMO.  California is a great case in point as all the big companies are now on board with GCS/SRS and they actually save money vs paying for treatment of depression, suicide and more.  Keeping people healthy and engaged is simply cheaper than paying for the fallout of non treatment.  Countries with a functioning National Health System can also demonstrate that truth.

Timing is probably another critical factor. If the current policy was purchased with the exclusionary clause, THEN the law was changed that insurers had to include GCS, the coverage wouldn't take effect until the next Open Enrollment period where they would have to offer policies that had the Inclusionary Clause. I'm not a lwayer but work in Hospital Reimbursement and also know a bit about benefits.