Well, it came down a little differently - more like this - but the general idea was right:
In 1999, Cal. Health & Safety Code 1367.63 went into effect (
http://www.dmhc.ca.gov/library/stat...ebhelp/___1367.63._Reconstructive_surgery.htm) It requires that medical insurance plans in California that are fully-funded (subject to CA Dept. of Insurance/DMHC regulation) pay for reconstructive surgery when the patient needs
"surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following(1) To improve function.
(2) To create a normal appearance, to the extent possible." [NO MEDICAL NECESSITY REQUIREMENT]
This law was prompted by a case where a young boy who was born without ears and deaf (permanently) was denied recon surgery to give him [medically unnecessary, because he'd still be deaf] outer ears to make him at least look a little more normal.
By 2007, when I applied for recon surgery, nobody had ever (to my knowledge) used this provision to try to get post-bariatric skin removal covered.
I was denied by HealthNet, appealed my denial, and it went to the DMHC. And they ruled in my favor, and ordered HealthNet to cover my surgeries. And HealthNet refused to comply. An action against HealthNet was instituted by the DMHC, but it was going to take a long time.
So I found a class action lawyer and convinced them to take the case. It took a few years (in fact, the issue that turned the tide was the DMHC finally getting HealthNet to consent and concede they should not have denied as not medically necessary), but the class action/multiparty case was settled, to my satisfaction. The issue in the case was whether morbid obesity was a disease that qualified under the statute (the actual issue, for the lawyers, was insurance bad faith failure to pay a claim). Take a look at what HealthNet agreed to in the DMHC portion of the case:
Following the survey, the Plan acknowledged that surgical procedures to remove redundant skin
following weight loss from bariatric surgery may qualify for coverage as “reconstructive
surgery” under Health and Safety Code section 1367.63 if the redundant skin constitutes
abnormal structures of the body caused by congenital defects, developmental abnormalities,
trauma, infection, tumor or disease and the procedure is to either improve function or create a
normal appearance, to the extent possible. The Plan also acknowledged that it will not deny
authorization for such skin reduction procedures on the basis that morbid obesity is not a disease
within the meaning of Section 1367.63.
HOWEVER: Unfortunately, based on the recently issued follow up survey, HealthNet just got better at papering their denials:
http://www.dmhc.ca.gov/library/reports/med_survey/surveys/300fsnr111113.pdf But - at least they are arguably applying the law, even if they are making subjective determinations all against the patient.
While I was working with the law firm on my case, they wanted to go after another insurance company. I checked around with my DS friends and found them a lead plaintiff for that case. It turned out to be MUCH bigger, and the results are publicly available:
http://gilardi.com/bluecrosslitigation/pdf/CourtOrderandJudgmentreFinalApproval.pdf ($3.2M settlement).
And there is a case against Kaiser which was just certified as a class action:
http://apps.alameda.courts.ca.gov/d...mgviewer.html&rofadt=12/23/13&Action=29640525
http://apps.alameda.courts.ca.gov/d...action.html&CaseNbr=RG12616206&CurrBatchNbr=1
The lawyers in the cases are:
http://www.gmlawyers.com/Health-Insurance-Claims/Reconstructive-Surgery-Claims.aspx
If you're in CA and would like to take a case against your insurance company, give them a call! Tell them I sent you - though I don't get anything for it.
