OAKLAND, Calif. (CN) – A class of patients alleges in state court that Kaiser refuses to cover reconstructive skin surgery after procedures for morbid obesity.
Filed in Alameda County Superior Court, they say that the refusal of Kaiser Foundation Health Plan to pay for removal of excess skin after bariatric surgery, such as a gastric bypass, violates Health and Safety Code Section 1367.63.
The statute requires health care service plans to cover reconstructive surgery performed “to correct or repair abnormal structures of the body” that is necessary “to improve function” and “to create a normal appearance.”
However, rather than investigate whether the proposed reconstructive surgery is necessary to restore or improve normal function, according to the complaint, Kaiser automatically denies those requests on the grounds that such surgery is merely “cosmetic.” Kaiser then refers its members to its for-profit cosmetic surgery centers.
Lead plaintiff Wendy Gallimore, who is covered under a Kaiser health plan as an employee of the Twin Rivers Unified School District, requested that Kaiser authorize reconstructive surgery for the mass amounts of excess skin left over from extensive weight loss following bariatric surgery. Her surgery was for repair of “abnormal structures of the body caused by…disease.”
There was no other appropriate procedure for plaintiff’s condition, said Gallimore in her complaint. However, Kaiser refused to authorize the surgeryess skin was “cosmetic.”
Adding insult to that injury, Kaiser incorporated Health and Safety Code Section 1367.63 into its “evidence of coverage” contract, said Gallimore, but did not abide by it.
The plaintiff class seek an injunction requiring Kaiser to re-evaluate its prior refusals of reconstructive surgery, as well as a declaration of rights and duties under Kaiser’s contract