TLC is thrilled that a nearly three-year health plan appeal has successfully been resolved in favor of our client, Kate. Kate is a transgender woman who lives in Southern California. After her therapist and her primary care physician recommended SRS to treat her Gender Dysphoria, Kate’s HMO refused to provide coverage due to an exclusion for transition-related care in her insurance policy. We helped her appeal that denial in 2012, arguing that this denial violated California law. The state’s Insurance Gender Nondiscrimination Act (IGNA), passed in 2005, prohibits health insurers from discriminating based on gender identity. In 2013, the California Department of Managed Health Care (DMHC) issued explicit guidance for the first time ordering California’s HMO health plans to remove blanket exclusions of coverage that target healthcare needed by transgender people, in order to comply with IGNA.
After the insurance company rejected the internal appeal, we helped Kate appeal the denial of coverage to DMHC, with the pro bono assistance of attorney Mattheus Stephens. After reviewing supporting documents from Kate’s physician, surgeon, and therapist, DMHC and Kate’s HMO finally determined that providing coverage for SRS was medically necessary to treat Kate’s Gender Dysphoria, and the HMO agreed to cover it.
“I couldn’t be happier about this news, after what seemed like an eternity of waiting and watching the mailbox,” said Kate. “I am very very grateful for Transgender Law Center’s excellent help with my appeal. I hope my case helps make it easier for the next trans person who needs this kind of treatment. No one should be denied essential health care just because of who they are.”
If you believe you’ve been denied health care in violation of IGNA, please contact the Department of Managed Health Care’s help line at 1-888-466-2219 or contact Transgender Law Center for assistance: www.transgenderlawcenter.org/help