Californians needing Reconstructive Surgery

In the process of looking into having reconstructive surgery, I discovered that there is a 1999 CA statute MANDATING that insurance companies provide coverage in CA of reconstructive surgery for excision of excess skin post-bariatric surgery, WITH NO REQUIREMENT FOR MEDICAL NECESSITY (i.e., like there is no requirement for breast reconstruction post-mastectomy). The CA Dept. of Managed Health Care agreed with my analysis of the statute, supported by letters from my surgeons that established that I meet the requirements of the statute. DMHC ORDERED Health Net to pay for ALL of my reconstructive surgeries. But Health Net refused to comply with this order! The case has been sent up to the DMHC Division of Enforcement, but there is no telling how long it is going to take for this to be resolved. It could be weeks or a few months -- if they decide to enforce it at all (although they assure me that they are taking this case very seriously). So, in the meantime, I have contacted a law firm specializing in such cases, and I am trying to get them to take it on as a class action. One of my arguments is that there are SO many potential clients! So, I have decided to provide a TEMPLATE version of the letter I had my surgeons fill out and sign, so that all Californians who are interested in getting their insurance companies to pay for their reconstructive surgery, without having to prove medical necessity, can get their cases in line to join the case. Please bring this letter to your plastic surgeon, and ask him to personalize it for your case (you may want to email it so s/he can just fill in the information and print it on letterhead). Submit with your request for approval, or with your appeals. Appeal all the way to the DMHC or the CA Dept. of Insurance (whichever is appropriate), and DO NOT GO THROUGH IMR, but rather file a GRIEVANCE! IMR will only result in DOCTORS agreeing that you have no medical necessity; you need to file a GRIEVANCE so the lawyers can look at the statute and enforce it. If you use this letter, I ask you to please send me your name and email address to my email account (dianahc AT comcast.net), using as the subject line "Class Action: Reconstructive Surgery". You may or may not be contacted by the attorneys (assuming they take the case), but at the very least, I want to keep track of the numbers of people potentially affected and thus potentially members of the class. The document is attached to this post: http://www.duodenalswitch.com/forum/showthread.php?p=65757#p ost65757 . Please don't be afraid to do this -- and please tell your plastic surgeon to use the template letter as well, and to PLEASE send me a notice of having used it to bolster the class action case. The law is clear, and the message to the insurance companies should be that the law should be enforced!

go get em Diana! if anyone can win this, i have faith it will be you! judi

Diana, It's awful to have to hire a lawyer to get an insurance company to obey the law! How did you find out about the California law?  I would like to research this for Tennessee but don't know where to start. Thanks, Jean

Findlaw.com.  There is currently a FEDERAL law pending that has very much the same language, EXCEPT that it includes a requirement for medical necessity -- please see this thread and WRITE YOUR CONGRESSMAN! Here is a post about both the CA statute and the pending Federal legislation: http://www.obesityhelp.com/forums/amos/a,messageboard/action ,replies/board_id,4856/cat_id,4456/topic_id,3452784/

Hi Diana   I wpuld like very much to see your letter but it won't allow me access to it. Please let me know how I can view it. Good luck with this. I am a Kaiser patient I wonder if it wil work for me. Please keep me posted on your progress and if I can do anything to help. I also would like to know where to find a copy of the law.                                                                                                            GOOD LUCK!                                                                                                             Nancy

I don't know why you can't see it -- I logged out and I could still open the document. The law is in the link posted in the post above.

I had to log into my www.duodenalswitch.com account before I could open it.

That's odd -- I logged out of my DS.com account and could still open it. ETA: Bah.  Although I can open it while logged out, my DH can't.  I thought I had posted it where it was publicly accessible.  Well, you know us DSers -- we ALWAYS have cookies! Oh well, maybe it's not such a bad thing if people have to open DS.com accounts to open the file.

This is good to know! Thinking of moving to CA.

Hijack!! Love your avitar Sophie,I would love to be able to afford a Hyacinth Macaw,but I am happy with my African gray parrot. Debbie