It looked like a frivolous issue. Self-proclaimed transgender person Ida Hammer, who was legally a man but wanted to be a woman, asked his health insurance company to pay for sex change surgery. His insurer, MVP Health Care, like most other health insurers, said "no." Labeling it "a cosmetic procedure," MVP Health twice denied his appeal.
But Ida wouldn't take no for an answer. The 34-year-old New York City resident lined up influential supporters and threatened to sue. When Ida's insurer learned who was backing him, it caved.
'Dog Day Afternoon'
This now national story has taken on a life of its own, drawing comments from people around the country, some of them straight, others gay, lesbian and transgender, but most of them negative. And the public outcry is understandable. Health insurance costs nearly $16,000 per family. And with rates rising, why should this elective procedure, costing between $18,000 and $50,000, be paid for by health insurance plans?
"In the old days when someone wanted a sex change, they just robbed a bank," said a writer for The Gothamist, referring to the 1975 Al Pacino movie Dog Day Afternoon, in which Pacino's character attempts to rob a bank to pay for his lover's sex change.
Those of us who have health insurance want our doctor's visits, medicines and procedures covered each year by our normally tightfisted health insurers. But many of us are turned down and have to appeal, often multiple times.
Just how many? A Georgetown University researcher called it "one of the dark corners of the black box of private health insurance." According to insurers they don't keep track of how many claims are turned down, but I did find a General Accounting Office (GAO) report showing that in California nearly a quarter of all claims were denied in 2009.
Follow in his/her footsteps
Instead of berating Ida, perhaps we should treat her as a pioneer who, by becoming very vocal and going public, showed us the way to pry open that "black box" and force insurers to pay. Even though the steps she took may not work for all of us, it's worth following in her footsteps.
- Appeal. A GAO study found that an appeal has a 50/50 chance of being changed, often because the rejection involves a coding or eligibility issue. Insure.com shows you how.
- Doctor's backing. Often your doctor will help. Ida's doctor claimed that Ida had a "gender identity" disorder which, if uncorrected, could turn Ida into a serial killer.
- Research. U.S. insurers routinely deny sex change surgery, but Ida pointed out that the American Medical Association supports the procedure. And the National Health Service routinely pays the bill in the United Kingdom.
- Influential group backing. Ida was supported by the Transgender Legal & Education Fund in her quest for a sex change. No publicity-shy insurer relishes the thought of a trial with people shouting and waving banners outside the courthouse.
- High-profile lawyer. Ida was represented by the prestigious Wall Street firm of Debevoise & Plimpton. Looks like MVP Health Care's lawyers chose to settle rather than go up against their high-powered counterparts. The relatively small insurer with 750,000 members in only three states probably did some quick calculations and found that it would cost more to fight than settle.
So remember: See your case as a cause, as Ida did, and justice might prevail.