Re: Legal Opinions

[Guest guest]

Please understand that the Indiana statute requires an OFFER of coverage for morbid obesity by design. This is how the legislature that passed the law intended for it to operate. The employer CAN choose to not take that offer. Other coverages (such as reconstruction for breast cancer) are required by law and there is no choice on either the employer or the insurer's part. There is a distinct difference between a "mandate" to OFFER coverage versus a "mandate" to PROVIDE that coverage. That is one of the several weaknesses in the Indiana statute. Hope that helps.

Walter Lindstrom, EsquireObesity Law & Advocacy Centerwww.obesitylaw.com2939 Alta View Drive - Suite O-360San Diego, CA 92139Tel: Fax:

Legal Opinions

Dear Listmates: the information which follows is taken directly from the Indiana Code as established earlier this year. The section of code known as IC 27-13-7 also includes requirements to provide coverage for mental illness; prosthetic devices and reconstructive surgery associated with mastectomies; etc. Please look at IC 27-13-7-14.5 ©. To me, it clearly states that a health maintenance organization which provides basic health care services under a group contract shall offer coverage for nonexperimental, surgical treatment by a health care provider of morbid obesity.

My HMO has provided me with a certificate of coverage which excludes treatment for Obesity, not Morbid Obesity, and has verbally informed me that the responsibility for coverage for WLS is dependent on the Employer making such a choice. If that is true, then does the employer also have the option of not providing reconstructive surgery following a mastectomy? or, looking at IC 27-13-7-15.3, can the HMO refuse to provide mammography as a covered service?

(" a health maintenance organization issued a certificate of authority in Indiana shall provide breast cancer screening mammography as a covered service under every group contract that provides coverage for basic health care services.")

Or, finally, can a HMO refuse to provide prostate specific antigen testing as provided for in IC 27-13-7-16?

("a health maintenance organization issued a certificate of authority in Indiana shall provide prostate specific antigen testing as a covered service under every group contract that provides coverage for basic health care services.") © Except as provided in subsection (f), the coverage required under subsection ( must include the following: (1) At least one (1) prostate specific antigen test annually for a male enrollee who is at least fifty (50) years of age.")

IC 27-13-7-14. Sec. 14.5. (a) As used in this section, "health care provider" means a: (1) physician licensed under IC 25-22.5; or (2) hospital licensed under IC 16-21;that provides health care services for surgical treatment of morbid obesity. ( As used in this section, "morbid obesity" means: (1) a weight of at least two (2) times the ideal weight for frame, age, height, and gender as specified in the 1983 Metropolitan Life Insurance tables; (2) a body mass index of at least thirty-five (35) kilograms per meter squared with comorbidity or coexisting medical conditions such as hypertension, cardiopulmonary conditions, sleep apnea, or diabetes; or (3) a body mass index of at least forty (40) kilograms per meter squared without comorbidity.

For purposes of this subsection, body mass index equals weight in kilograms divided by height in meters squared. © A health maintenance organization that provides coverage for basic health care services under a group contract shall offer coverage for nonexperimental, surgical treatment by a health care provider of morbid obesity: (1) that has persisted for at least five (5) years; and (2) for which nonsurgical treatment that is supervised by a physician has been unsuccessful for at least eighteen (18) consecutive months.As added by P.L.78-2000, SEC.3. It seems quite obvious to me that the WLS coverage is not an option left up to the employer, but a requirement. If not, why even bother to mention it? I am completing my appeal packet and am going to include this interpretation of Indiana Law in the request to both the HMO and to the employer. What do you think? By the way, I have already sent this to Walter, Kathleen, and Nina, with an attachment of the full text of IC 27-13-7 but the list mailings will not take attachments.

B458#, BMI 74Pre-op for DSStill fighting!