Legal Question in Insurance Law in Oregon
TMJ suffers not covered by HMO
I have suffered from Temporomandibular Joint Problems (TMJ) for about two+ years. My insurance policy states that they will not cover TMJ related problems. I feel that this is discirimination because this is a condition that effects every aspect of my life causeing severe headaches, sleeping, eating, and talking problems. I am at no time without pain and the condition will continue to increase without costly treatment that I presently cannot afford and yet can not put off. I see TMJ as a disability because as this conditin persists, without the appropriate intervention, it will greatly effect my education, career path, and therefore my future. My insurance claims that TMJ is a dental problem and at other times that it is a cosmetic condition. It is neither, clearly I have a medical condition envolving the jaw joint and surrounding muscles. Not covering TMJ problems, I feel is like refusing to cover other similar conditions that they must cover. Do I have any kind of arguement that my challenge my HMO?
2 Answers from Attorneys
HMO denying coverage for TMJ
No easy answer. If this HMO is through your employment, your rights are limited by ERISA, unfortunately.
How long have you had this plan? When did you sign on, relative to the TMJ symptoms. If they changed their plan midstream, you might have a better shot.
TMJ has been controversial, because a few years ago, nobody ever heard of it, and then some dentists of dubious integrity latched on to it and figured they could get rich finding and treating TMJ problems. John Stossel of ABC did an expose report on one of these guys in Philly, which led to a libel suit (which the dentist lost).
These is not any general legal rule which requires a health insurance plan to cover every medical condition and treatment. So your remedies may lie more in some procedural theories. But only a skilled health care attorney in your state can really tell if you have any basis for a claim.
Here's a web site with good information about HMO's: http://www.harp.org
The above does not constitute legal opinion and is offered for the purposes of discussion only. The law differs in every jurisdiction, andyou should not rely on any opinion except that of an attorney you have retained, who has a professional duty to advise you after being fullyinformed of all the pertinent facts and who is familiar with the applicable law.
TMJ/Insurance law
Mr Marvin is correct as far as it goes. Without seeing your health plan documents no valid opinion can be provided.
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