Temporomanidibular Joint Disorders

Insurance Commissioner's signature CT state seal STATE OF CONNECTICUT INSURANCE DEPARTMENT BULLETIN NO. HC-47 August 8, 1991 TO: ALL INSURANCE COMPANIES AND HEALTH CARE CENTERS LICENSED TO WRITE HEALTH CARE COVERAGE IN CONNECTICUT RE: TEMPOROMANDIBULAR JOINT DISORDERS This Department has reviewed numerous complaints from consumers who were denied benefits under the medical expense portion of their respective health insurance policies for treatment of Tempo{omandibular Joint Dysfunction (TMJ). We wish to bring to the attention of all health insurers and health care centers with policies in force in Connecticut, a recent decision of the United States Court of Appeals for the Second Circuit, MBsella v . Blue Cross & Blue Shield of COiln~ticut, Inc., No. 90-7992 (6/19/91) (1991 WESTLAW 105219) (2nd Cir. 1991). The Court affirmed the decision of a U.S. District Court for the District of Connecticut which found that the ncin-surgica l treatment of TMJ was "medical" rather than "dental" in nature, and, therefore, did not fall within the insurer's policy exclusion fnr dental care and treatment. In reaching this conclusion, the Court stressed "the nature of the procedure performed rather than ... the title of the one who performs it and that services performed by a dentist are not necessarily excluded from coverage." (ill.._, slip opinion at p. 22) . In the absence of unusual factual circumstances, as a result of this decision by the Second Circuit, we expect that unless there is a specific policy or contractual exclusion for treatment of TMJ, any treatment: of TMJ, whether surgical or non-surgical, will be deemed to be medical in nature and therefore not subject to the standard policy exclusion for dental care and treatment. With respect to past claims for benefits, we expect that all insurers and health care centers will review any claims which were denied for the treatment of TMJ f o r the purpose of correcting improper denials. u-C(h~ T R. GOOGINS Commissioner