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Dr. Rebecca L. Griffiths |
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TMJ - Law Information HelpTMJ is a Medical Disorder:In Masella v. Blue Cross & Blue Shield of Connecticut (United States Court of Appeals for the Second Circuit, 1991), plaintiff was diagnosed in 1985 as suffering from temporo. mandibular joint dysfunction or TMJ, a painful disorder of the jaw joint. As a result, she received non-surgical treatment, including biofeedback and an orthotic, an appliance that fit on the plaintiff's teeth and was intended to reposition part of her jaw joint. When the plaintiff submitted the claims to her insurer for payment, they were rejected. The basis for the insurer’s declining the claims was that the treatment was dental in nature (rather than medical) and was thus excluded from coverage under the relevant health insurance policies. The plaintiff then commenced an action seeking to recover the denied benefits. After the trial court found in favor of the plaintiff, the insurer appealed. The United States Court of Appeals for the Second Circuit affirmed, ruling that TMJ was a medical, rather than a dental disorder and was covered under the relevant policies.
RESULTS OF COURT CASES FOR HEAD, NECK AND TMJ DISORDERS1 - Ponder v. Blue Cross of Southern California, 193: Rptr. 632, Cal App. 1983: The health insurance policy had an exclusion denying payment for dental care including "treatment for or prevention of temporomandibular joint syndrome" The Appellate Court held that this was not an effective exclusion. 2 - Jowers v. Nationwide No. CV 85-, 2 December 1986 Terrolyn Jowers recovered $703.00 medical expenses, $175.75 Bad Faith Penalties, $5,000 attorney's fees and $1,000,000 punitive damages for her TMJ treatment whicb was originally denied by tbe insurance company. 3 - Goss v. Medical Service of the District of Columbia et al, District of Columbia Court of Appeals, No. 81 - 1276, 13 June 1983 Blue Cross/Blue Shield's position was tbat putting crowns on tbe teetb is considered dentistry. The Patient's position was that the crowns were medically necessary to correct a malpositioned jaw. Court results: "There was no need for tbe crown and bridge work independent of the TMJ. In fact the crowns were directly related to, and required by, the medical condition of Mrs. Goss' jaw. The treatment was not required to, and did not treat any condition of Mrs. Goss' teeth or tooth relationship as Mrs. Goss' teeth were used to support the devices required to stabilize the position of her jaw." Blue Cross Blue Shield was ordered to pay for the treatment. 4 - Robinett v Metropolitan Life Insurance Company, 404 So. 2d 1344 1981 (Louisiana): "The appliance used to treat the patients condition was not an end in itself but rather was intended to relieve pain from her mandibular joint rather than to correct her dental problems. Reasonable minds would not inevitably conclude that, as a matter of law, procedures performed on her were "dental services" excluded from coverage under health policy." Sample Letter Mr. Attorney Attorney & Counsellor at Iaw 205 South Main Street Any City Vermont 300-555-2726 April 18, 1995 Mr. Claim RE: My Client/Claimant: XXXXXXXXXX Dear Mr. Claim: Please be advised that XXXXXXXXXX has retained me to represent her for the purpose of securing health insurance coverage for surgery of her temporomandibular joint. I reviewed your letter to XXXXXXXXXX dated March 15, 1995 denying her request for coverage of this surgery. I have also reviewed XXXXXXXXXX policy with particular attention to page 9, Exclusion and Limitation No. 4. On behalf of XXXXXXXXXX please consider this letter as a request to reconsider your position and declare this surgery as compensable under the above-referenced policy. There are numerous cases in which courts have held that treatment and/or surgery of the temporomandibular joint was covered under a policy of insurance despite a clause in the policy excluding such coverage. For example, in Pondet v. Blue Cross of Southern California, 193 Cal Rptr. 632 (Cal. App. 1983), the Court held that an exclusion under a health insurance policy denying payment for dental care including "treatment for or prevention of temporomandibular joint syndrome" was not an effective exclusion. In Goss v. Medical Service of the District of Columbia et al., District of Columbia Court of Appeals No. 81-1276 (June 13, 1983), the Court held that the placement of crowns and bridges on the teeth in the course of treatment of temporomandibular joint syndrome was a medical condition and therefore did not fall under the category of "dentistry" as set forth in the policy. In Kobinett v. Metropolitan Life Insurance Company. 404 So.2d 1344 (La. 1981), the Court ruled that dental equipment used to treat a patient's temporomandibular joint was intended to relieve pain arising from said joint rather than to correct "dental problem" and was therefore covered under the policy. The Exclusion and Limitation No. 4 contained in XXXXXXXXXX policy is ambiguous. Dental care and treatment is covered when "required to treat covered injuries to whole natural teeth." Although the term "injury" is defined on page 5 of the policy, it simply states that an injury is any "accidental bodily harm." The term "covered injury" as set forth in Exclusion and Limitation No. 4 is not defined and is vague since dental care and treatment is excluded from coverage. Although the policy states that "disorder" of the temporomandibular joint are excluded from coverage, the term "disorder" is also vague especially since the term "covered injury" is not defined. XXXXXXXXXX suffered an injury to her temporomandibular joints as a result of an automobile accident in which she was rear ended without any warning. Her injuries arise from "accidental bodily harm" as defined in her policy. Her injury also impacts on her teeth since the temporomandibular joint is affected. Her injuries illustrate the ambiguity in your policy. It is basic contract law that an ambiguous contract or insurance policy shall be construed against the author. It also appears that the insurance policy is an adhesion contract since XXXXXXXXXX had no opportunity to bargain for certain coverages which your company has unilaterally excluded. There are numerous other cases and statutes which support the cases and the principles cited herein. I urge you to reconsider your position so that the parties can avoid needless and expensive litigation. I would appreciate your response within ten (10) days of your receipt of this letter. If you choose not to respond or advise me that your position remains unchanged, then we will have no choice but to file suit in order to obtain coverage for XXXXXXXXXX surgery. I hope we can avoid that scenario. Thank you for your attention to this matter. I look forward to hearing from you soon. 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