Claim for short term disability leads insurer to change policy

On Behalf of | Mar 19, 2019 | Denied Private Disability Ins. Claims |

As more people are becoming accepting of transgender surgery, insurance companies are changing policies. In this vein, a major disability carrier recently did so after initially denying a claim. This is good news for the transgender community in Florida as many are hoping other carriers follow suit.

In a recent case in Massachusetts, the claimant filed for short term disability due to male-to-female transition surgery. The recovery time was estimated to be four to six weeks. The claimant’s policy paid short-term benefits after seven working days. However, ‘elective surgery” was listed as an exclusion under the policy. The type of procedure undergone by the claimant was considered elective by the carrier.

Though the claimant sent a doctor’s report regarding the medical necessity of the surgery, the claim was denied. The claimant contacted an LGBT advocacy group that agreed to help. A long fight with the carrier was anticipated. Instead, the insurer paid the claim without further appeal procedures.

More surprisingly, the claimant and advocate learned that the insurer eliminated the exclusion if the procedure was medically necessary. A spokesperson for the company alluded to the fact that the medical field is coming to an agreement that transgender surgery is a medically necessary procedure for some. For example, gender dysphoria is now a clinical disorder recognized in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders.

The above case illustrates a reason for not abandoning a disability claim that has been denied. This is especially true when the reason for the claim is in an evolving area of medicine or a unique basis for the disability exists. A disability attorney can help a client articulate the basis for a disability and present a strong case to an insurance carrier.