Several years ago, I decided to pursue reconstructive surgery. In researching the insurance issues prior to requesting surgery, I discovered that there was a 1999 law mandating coverage of reconstructive surgery in California under the Knox-Keene Act, which applies to fully-funded insurance plans "delivered" in California (CAL. HSC. CODE § 1367.63):
In other words, there is no requirement for medical necessity, which is the excuse that the insurance companies essentially universally use to deny coverage. That law had never been enforced for post-bariatric reconstructive surgery.
I used that law in my appeal against my insurance company at the time, Health Net, and took my appeal all the way to the CA Dept. of Managed Health Care. The DMHC agreed with me and ordered Health Net to pay for ALL of my reconstructive surgeries. Health Net refused to comply with their order.
Although the DMHC pursued an action against HN on my behalf, I decided to find a class action attorney and convince them to pursue a separate claim for money damages and other orders that could affect other people "similarly situated." The law firm Gianelli & Morris took up the challenge, after I provided them with compelling arguments and evidence that they might have a good chance of winning (and thus recouping their investment - remember that class action suits are initially paid for by the law firm, and they take all the financial risk, including putting in time and money for expert witnesses, etc., that they will never get paid for if they lose).
Ultimately, that case was settled (so I can't talk about how), but the strategies developed to prepare the case against HN were then used as a template to sue other insurance companies. I helped the law firm find a plaintiff (also a DSer) for the case against Blue Cross of CA, the outcome of which IS public: http://gilardi.com/bluecrosslitigation/pdf/CourtOrderandJudgmentreFinalApproval.pdf - BC had to pay $3,200,000.
I also helped them (through posts I made on message boards inviting people with Kaiser to contact them) to find a plaintiff for their case against Kaiser, which is being tried before a judge right now. Here is a report of the opening statements on Monday, March 16, 2015, including some video of those statements: http://www.lexisnexis.com/legalnews...for-excess-skin-removal-watch-the-videos.aspx
I assume that, as before, in order to be part of that class, you have to at least have requested reconstructive surgery from Kaiser and been denied.
http://www.courthousenews.com/2015/03/17/surgery-patients-take-kaiser-to-trial.htm:
"Gallimore's attorney Robert Gianelli argued in opening statements that the class likely contains 10,000 patients."
If you might be part of that class, or know someone who is, you may want to contact the law firm.
In other words, there is no requirement for medical necessity, which is the excuse that the insurance companies essentially universally use to deny coverage. That law had never been enforced for post-bariatric reconstructive surgery.
I used that law in my appeal against my insurance company at the time, Health Net, and took my appeal all the way to the CA Dept. of Managed Health Care. The DMHC agreed with me and ordered Health Net to pay for ALL of my reconstructive surgeries. Health Net refused to comply with their order.
Although the DMHC pursued an action against HN on my behalf, I decided to find a class action attorney and convince them to pursue a separate claim for money damages and other orders that could affect other people "similarly situated." The law firm Gianelli & Morris took up the challenge, after I provided them with compelling arguments and evidence that they might have a good chance of winning (and thus recouping their investment - remember that class action suits are initially paid for by the law firm, and they take all the financial risk, including putting in time and money for expert witnesses, etc., that they will never get paid for if they lose).
Ultimately, that case was settled (so I can't talk about how), but the strategies developed to prepare the case against HN were then used as a template to sue other insurance companies. I helped the law firm find a plaintiff (also a DSer) for the case against Blue Cross of CA, the outcome of which IS public: http://gilardi.com/bluecrosslitigation/pdf/CourtOrderandJudgmentreFinalApproval.pdf - BC had to pay $3,200,000.
I also helped them (through posts I made on message boards inviting people with Kaiser to contact them) to find a plaintiff for their case against Kaiser, which is being tried before a judge right now. Here is a report of the opening statements on Monday, March 16, 2015, including some video of those statements: http://www.lexisnexis.com/legalnews...for-excess-skin-removal-watch-the-videos.aspx
I assume that, as before, in order to be part of that class, you have to at least have requested reconstructive surgery from Kaiser and been denied.
http://www.courthousenews.com/2015/03/17/surgery-patients-take-kaiser-to-trial.htm:
"Gallimore's attorney Robert Gianelli argued in opening statements that the class likely contains 10,000 patients."
If you might be part of that class, or know someone who is, you may want to contact the law firm.
Kaiser was willing to do the hernia repair and an abdominoplasty, just not in the same surgery, which is plain DUMB. Now they are dragging their feet to authorize the combined surgery that my IMR requires.
