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Home / Articles / News / News Articles /  Coverage Denied
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Coverage Denied

Trans Utahn fights SelectHealth

By Eric S. Peterson
Photo by Erik Daenitz // Sophia Hawes
Posted // October 19,2011 -

The gender reassignment surgery that Sophia Hawes underwent in May was a life-changing experience. She finally felt complete after years of being caught between identities since she’d started cross-dressing at age 16. After decades of doubt and confusion, lies to herself and her loved ones, a failed marriage and three failed suicide attempts, for the 46-year-old Hawes, waking up from the sex-reassignment surgery was like being reborn.

“The minute I woke up from surgery, I knew everything was right,” Hawes says. “Everything was perfect.” Finally being able to own her female identity—body and soul—Hawes considered the procedure she undertook by a renowned surgeon in Thailand to be a life-saving operation. Her health insurance didn’t see the operation that way, however, denying any coverage of the procedure for which she paid $16,000 out of pocket.

While Hawes had even had a broker agent provided by her employer confirm that SelectHealth policy booklet did not specifically exclude the procedure from partial coverage, Hawes was denied—and then some. SelectHealth also looked back over her file and denied coverage for certain treatments she had received before her surgery in May, arguing that those procedures—which included a test for a blood disorder Hawes has had all her life—were related to the reassignment surgery.

For Jude McNeil, a training director for LGBT advocacy organization the Utah Pride Center, transgender individuals regularly get discriminated against by the bureaucracy of insurance companies.
“People are being denied [medical] service just for being transgender—they get labeled,” McNeil says.

Hawes, a Maine native, has spent her whole life looking for herself. When she was in college in the early ’80s, being a woman meant cross-dressing and growing her hair out and praying that God would change her body. It wasn’t until the late 2000s, however, after years of counseling and eventually hormone therapy, that Hawes made the full surgical transition into womanhood and sought to have her insurance provide partial coverage.

“This is a medical procedure that is neither cosmetic nor experimental,” Hawes says, referring to a recent resolution by the American Medical Association supporting insurance coverage of treatments that include gender-reassignment surgery for treatment of gender-identity disorder (ed. note: this sentence has been corrected to clarify the AMA's position). Without treatment, those diagnosed with GID can suffer “psychological distress” and “debilitating depression” that can lead to suicide and death. Hawes knows these symptoms personally.

In 2006, Hawes was 41 and married with two daughters and realizing her identity was a lie to her wife and to herself. After seeking therapy, Hawes decided she had to change. When Hawes told her wife, however, and began taking hormone therapy, the marriage became traumatic.

“It was like living with my own ghost,” Hawes says. “She grieved the loss of her husband. I tried on three separate occasions to kill myself because I couldn’t go back and get her to see me the way I was.”

After a painful split, Hawes continued on with the therapy and made the final transition with her surgery in May. She knew that she could only even attempt to claim the insurance coverage by following the AMA’s guidelines, meaning that she received an official GID diagnosis, then began hormone therapy a year later and had the final reassignment surgery almost four years later.

SelectHealth, however, has disagreed and is now challenging Hawes’ appeal. According to the members booklet provided to Hawes, reassignment surgery is not listed as an excluded procedure, but as a spokesman pointed out, it’s also not listed under covered services. The booklet does not list all specific covered services, but SelectHealth spokesman Spencer Sutherland says standard plans don’t cover the procedure. While not able to speak about specific clients, Sutherland wrote, via e-mail, “Additionally, we do not treat complications from non-covered services.”

Although Hawes understands SelectHealth’s own booklet is vague about the procedure, she was stunned when, in the months following the claim denial, SelectHealth denied her coverage on medical visits that happened before her reassignment surgery. The denied visits included a genetic testing related to a blood disorder Hawes has had all her life, an emergency room visit related to a urinary-tract infection and a CT scan trying to pinpoint symptoms resembling menstrual pains.

The CT scan, Hawes says, may have been most perplexing to doctors, since Hawes believes she may have been born with female tissue. Throughout her life, she’s had pains similar to menstrual cramps, and through granular tissue had even experienced bleeding in the past. These symptoms of a possible undiagnosed intersex condition became more frequent after she started hormone therapy.

With her doctors still not being able to identify the mass of tissue, Hawes says the CT scan was necessary to make sure it wasn’t a tumor. But now she worries about how she will be able to afford further tests and treatments that might be necessary to ensure the tissue isn’t cancerous.

“I’m afraid that if anything occurs going forward, they’re going to label it as a complication” related to the gender-reassignment surgery and deny coverage, Hawes says.

McNeil says that “100 percent” of trans individuals with health insurance have made similar complaints to her. She points out that menopausal women regularly take hormone therapy without being flagged by their insurance company.

“But it’s only when people take hormones for transgender [issues], then all of a sudden there’s all these risks,” McNeil says. She says the flagging problem affects doctors, as well, adding that she only recommends patients to one trans-friendly doctor in the state.

Matt Wood, an attorney at the Transgender Law Center in San Francisco, says most insurance companies discriminate against transgender members like Hawes by failing to recognize that trans-related procedures are more than “cosmetic.”

“Even ‘cosmetic’ treatments can also be medically necessary when there is strong medical evidence that the treatment is effective,” Wood writes via e-mail. “Insurance policies often cover breast reconstruction for breast-cancer survivors if the patient’s doctor determines that it is appropriate and medically necessary.”

Hawes doesn’t regret her transition even after all her insurance troubles. She now lives the life she wants, splitting her time between her job, her church, running a trans support group and her new passion of belly dancing. Unfortunately, fighting back against her insurance company is something she feels she has to do even if she doesn’t want to, especially after being denied coverage on ailments unrelated to her transition.

“It feels like retaliation right now,” Hawes says. “Whether or not that’s the intent, that is the effect.”


Twitter: @EricSPeterson

 
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REPLY TO THIS COMMENT
Posted // November 12,2011 at 11:10 Dear lord that is a manly ass tranny. I don't care what elective surgery someone chooses to have but you better have the money to pay for something as ridiculous as this. Belly dancing trannies!?!?! These stories are hilarious.

 

Posted // November 15,2011 at 19:04 - Hi Tom,

Despite how hurtful and offensive your comments are, they reveal a certain amount of ignorance.

Of course, some people will see residual male features in practically anyone who transitions mid-life. That's why there are new recommendations for adolescents with gender identity disorder that allows them to block the hormonal effects early.

Belly dancing is my life choice and I am accepted amongst the dancers and friends. I don't care whether you or anyone else finds it amusing or not. That's not why I do it.

In addition, I am sorry to hear that you consider the surgery elective, because it was a life or death decision for me.

Anyway, I'm glad you are getting a good laugh out of my pain. At least someone feels good.

- Sophie

 

REPLY TO THIS COMMENT
Posted // October 19,2011 at 16:52 Bill, actual knowledge of the condition would also help. Yours is a false argument. There's a solid body of evidence starting in about 1994. Neurologists now know that there are sexually dimorphic areas of the brain and they develop 'opposite' what you'd espect in trans people. Including the brain's map of the body. Nose shape and the like on the other hand are culturally specific fashions. Your arguments against complications is equally false as the rate of complication is the same as any other surgery.

 

Posted // October 21,2011 at 10:12 - Hi Bill,

You have some very valid points on how some people in the insurance organization have viewed the procedure in the past and some may still do in the present.

I am finding some empathy in the appeals department even though they denied my appeal on an exclusion that was listed in a rider.

I would like to hear more from you on any suggestions to persuade them that these arguments are not as sound as they think.

For instance, SRS, in my opinion should be viewed as reconstructive surgery for a congenital condition that restores functionality, which is usually not defined to include fertility.

That is in lieu of wording in the exclusion that says they will not treat Gender Dysphoria (exclusionary language). A misnomer for Gender Identity Disorder, dysphoria implies a state of mental confusion and would lead one to believe that it is a mental health condition.

Unfortunately, it is not a mental health condition. I never was confused about my gender. I was at a loss as to how to safely interact in a society when I didn't know SRS was available to me and certainly wasn't affordable.

In the 1990s, a physician at Johns Hopkins saw that there seemed to be no difference in feelings of hope between people who had SRS and those who were scheduled to receive it. So he shut the program down.

Suicides increased as people lost hope. Insurance companies misreading the data followed suit in their exclusions.

So it's important that the insurance do protect themselves from "whim" surgeries and that can be done by exercising models like those of Blue Cross Blue Shield and others that require the WPATH standards have been followed prior to surgery. Most people who transition using those standards find comfort without SRS. So there won't be a run on the benefits.

If it took you two years minimum through psychotherapy and other treatments before you could get your eyelid surgery, you might not mentally consider it worth the effort.

 

Posted // October 20,2011 at 10:09 - Sara (now I have to wonder if you were once a "Steve" ;-))the point I was making and you didn't get is that currently, insurance companies don't like it when you lop off perfectly good body parts, setting up a potential infection and complications situation where there wasn't one before, seeking a personal resolution to what they still consider mental illness. That's all. I didn't say it was a bad or good thing, just how the insurance companies must look at treatments and experimental procedures.

 

REPLY TO THIS COMMENT
Posted // October 19,2011 at 11:37 Let's also not forget that the IRS considers it a legitimate medical expense as well.
This stems from Sen. Helms' insertion of transsexual exclusion into the ADA where he tried to equate TS people with pedophiles and the like. From there the verbage was carried into a huge number of policies and documents, all because of bigotry.
The AMA recommends that the procedures be covered. There have been numberous instances that show that the cost of coverage is far smaller than that of non-coverage, even to the insurance company itself & even without having been preceded by a specific rider.
This is one of those cases of decisions being made in an irrational manner based on someone's moral values. Sadthing is, there is nothing immoral about it, either from a secular or Christian or other standpoint. Trans people are simply easy targets.

 

Posted // October 19,2011 at 14:30 - Actual knowledge of insurance coverage helps here. Reassigment surgery is no doubt seen as an elective procedure, regardless of gender or moral opinions. Just like the nose job I want because I've always felt weird and self-conscious with a big nose. It's affected my life, my happiness and my confidence throughout. But insurance will not cover rhinoplasty unless it's medically necessary to preserve my life. Same with eyelid surgery, whereas my lids droop so much at 61 years of age that I have to make a conscious effort to keep my eyes fully open. Otherwise, my eyelashes start to occlude my vision. Insurance won't cover it, even though I think it makes for dangerous driving, etc. It's an elective cosmetic procedure. If insurance companies started covering these kinds of personal, elective procedures, no one in this country could afford the resulting premiums.

And, the potential for post-operative complications from removing a perfectly good, working penis are such that insurance companies see the brand-new infections and problems coming before the first cut is made. There's nothing irrational about it. You may not like it, like my nose and eyelids, but it's totally rational.

 

REPLY TO THIS COMMENT
Posted // October 19,2011 at 08:40 I stand by you 100% my bellydance sister! So glad you have no regrets.

 

REPLY TO THIS COMMENT
Posted // October 19,2011 at 08:36 The problem's so bad that the AMA passed resolution 122, calling for such endemic discrimination to end.
Whereas,
Our American Medical Association opposes discrimination on the basis of
gender identity; and Whereas, Gender Identity Disorder (GID) is a
serious medical condition recognized as such in both the Diagnostic and
Statistical Manual of Mental Disorders 4th Edition (DSM-IV) and the
International Classification of Diseases (10th Revision), and is
characterized in the DSM-IV as a persistent discomfort with one’s
assigned sex and with one’s primary and secondary sex characteristics,
which causes intense emotional pain and suffering; and
Whereas,
GID, if left untreated, can result in clinically significant
psychological distress, dysfunction, debilitating depression and, for
some people without access to appropriate medical care and treatment,
suicidality and death; and
Whereas,
The World Professional Association For Transgender Health, Inc.
(“WPATH”) is the leading international, interdisciplinary professional
organization devoted to the understanding and treatment of gender
identity disorders, and has established internationally accepted
Standards of Care for providing medical treatment for people with GID,
including mental health care, hormone therapy and sex reassignment
surgery, which are designed to promote the health and welfare of persons
with GID and are recognized within the medical community to be the
standard of care for treating people with GID; and
Whereas,
An established body of medical research demonstrates the effectiveness
and medical necessity of mental health care, hormone therapy and sex
reassignment surgery as forms of therapeutic treatment for many people
diagnosed with GID; and
Whereas,
Health experts in GID, including WPATH, have rejected the myth that
such treatments are “cosmetic” or “experimental” and have recognized
that these treatments can provide safe and effective treatment for a
serious health condition and
Whereas,
Physicians treating persons with GID must be able to provide the
correct treatment necessary for a patient in order to achieve genuine
and lasting comfort with his or her gender, based on the person’s
individual needs and medical history and
Whereas,
Our AMA opposes limitations placed on patient care by third-party
payers when such care is based upon sound scientific evidence and sound
medical opinion; and
Whereas,
Many health insurance plans categorically exclude coverage of mental
health, medical, and surgical treatments for GID, even though many of
these same treatments, such as psychotherapy, hormone therapy, breast
augmentation and removal, hysterectomy, oophorectomy, orchiectomy, and
salpingectomy, are often covered for other medical conditions; and
Whereas,
The denial of these otherwise covered benefits for patients suffering
from GID represents discrimination based solely on a patient’s gender
identity; and
Whereas,
Delaying treatment for GID can cause and/or aggravate additional
serious and expensive health problems, such as stress-related physical
illnesses, depression, and substance abuse problems, which further
endanger patients’ health and strain the health care system; therefore
be it
RESOLVED,
That our American Medical Association support public and private health
insurance coverage for treatment of gender identity disorder as
recommended by the patient’s physician.

 

 
 
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