XFilesGeek's Guide to Transphobia!

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Let's try another one I've worked on recently:

(In the U.S.) transition-related coverage (such as sex reassignment surgery) is denied in most plans because it is merely cosmetic/elective (i.e. not medically necessary).

Let's take a look at one major insurer's bulletin on the medical necessity of sex reassignment surgery (SRS), Aetna:

http://www.aetna.com/cpb/medical/data/600_699/0615.html

If you look down, you can see there are criteria, which are actually not that difficult to meet, which would cause the insurer to consider the procedure to be medically necessary. In other words, in the eyes of this insuer sex reassignment surgery is medically necessary and not merely cosmetic/elective (as long as the easy to meet criteria are met).

But then let's look at a statement near the top of the bulletin:

What's this? I thought Aetna considered this procedure medically necessary and not merely cosmetic/elective, so why are they excluding it in most plans? Good question, and one that would probably take a whole book to answer. Nevertheless, you get the sense that there is a bit of arbitrariness here.

Last year, I spoke to a rep at my company's insurance administrator about coverage of sex reassignment surgery. He said point blank that it's excluded, because there is a specific clause written in the plan contract excluding it. I asked him, What if I provide documentation that it is medically necessary? He answered basically, It doesn't matter. The procedure is excluded in the plan. Note that he did not once describe the procedure as cosmetic or elective, much less use that as a reason for excluding coverage.

Sometimes insurance companies do rely on the cosmetic/elective exclusion, and sometimes they lose and are forced to pay out anyway, like here:

http://www.transgenderlegal.org/headlin ... php?id=384
http://www.transgenderlegal.org/media/u ... oc_467.pdf

Since for some mysterious reason, insurance companies still don't want to cover it, they take great pains to make sure to insert clauses specifically excluding it, so their statement of its being cosmetic/elective isn't used against them:

http://www.hrc.org/resources/entry/heal ... der-people

The system sucks as it is and for most of the country it doesn't look like it's going to change anytime soon. Insurance companies at the federal level and in most states have political cover for this and do not fear most regulators going after them for this. And this personally affects the lives, greatly, of many trans people in the good ol' USA.

if we could somehow get a kickstarter or indiegogo going in order to pursue legal action once the ACA has been fully implemented.