Hawaii’s workers’ compensation insurers are grappling with reimbursements for medical marijuana claims that are slowly trickling in as more doctors certify patients to use cannabis as an alternative to opioids.

The Hawaii Employers’ Mutual Insurance Co., otherwise known as HEMIC, the state’s largest provider of workers’ comp insurance, approved payment June 4 for one gram of marijuana flower and one bottle of cannabidiol per week to treat a patient with dizziness, headaches, concussion, a lumbar spine strain and major depressive disorder, according to documents obtained by the Honolulu Star-Advertiser.

After receiving calls from the Star-Advertiser, asking whether the approval marked a change in HEMIC’s policy against paying for medical marijuana, the insurer rescinded the approval June 25.

“This week we were made aware of an isolated incident that was the result of miscommunication about HEMIC’s policy regarding medical cannabis reimbursements for workers’ compensation claimants. After the situation was brought to our attention, we immediately denied the treatment plan and took the necessary steps to ensure that this type of situation does not happen again,” said HEMIC CEO Marty Welch in a statement to the newspaper. “HEMIC does not reimburse for medical cannabis for workers’ compensation claimants. The medical fee schedule under Hawaii’s workers’ compensation law follows the Federal Medicare fee schedule, which affords no reimbursement for medical cannabis.”

HEMIC has received a couple of inquiries about cannabis coverage, but this was the only formal request for reimbursement, Welch added. A year ago HEMIC canceled insurance policies and refunded premiums for seven medical marijuana dispensaries that were preparing to open for the first time in Hawaii, citing concerns over criminal liability because the drug is considered illegal by the federal government.

The Oahu patient, who was approved then later denied payment for marijuana, said she will appeal the denial because it is a legitimate medication for her ailments. The 38-year-old mother of four, who asked not to be identified by name, is hoping cannabis can replace the opioids she’s been taking since 2014 after a major car accident left her debilitated. The highly addictive prescription medicines have been blamed for creating a nationwide drug epidemic.

“This was the attempt to take away my spasms in my bladder and my back pain so I don’t have to be on hydrocodone. That’s the goal … to be completely off opiates. They cannot approve it and then deny it,” said the patient, who has been paying $150 for pakalolo every two to three weeks since beginning the treatment recommended by her doctor in February. “You don’t make a mistake like that. You’re playing with my livelihood. You’re messing with my life.”

Ready to fight

Her attorney Dennis Chang said he is prepared to fight the case, which would be the first of its kind for the state Department of Labor and Industrial Relations.

“There have been some cases on the mainland … a few cases where they have approved medicinal marijuana and related products. At the same time there are a lot of states that have not and have denied it. It’s going to involve brutal litigation (likely going) to the Hawaii Supreme Court,” said Chang, citing a 2015 Supreme Court case that ruled that insurers should provide needed medical care for the maximum rehabilitation of an injured worker. He said over the past two years he’s had about 50 clients who “refuse to ingest harmful drugs” and instead use medical marijuana.

“With that decision, they may likely rule in our favor. I’ve been waiting for (a medical marijuana case). It’s a big deal,” he added. “She tried very hard to get off (opiates) for a long time. Over and over. That’s probably the best thing that can happen in Hawaii instead of drugs — or opioids — for certain people during the recovery process.”

Disputes over insurance coverage for out-of-pocket medical expenses can be appealed to the state Department of Labor and Industrial Relations. A decision by the department director can also be appealed to the Labor Industrial Relations Appeals Board and further to the Intermediate Court of Appeals or Hawaii Supreme Court.

“We haven’t had any decisions issued by the director on that topic. We don’t really have any policy on it,” said DOL spokesman William Kunstman. “It’s more like each case is based on its own merit.”

Opioid vs. medical cannabis

Former Hawaii Medical Association President Dr. Scott McCaffrey, an injury recovery specialist who treats workers’ comp patients, said that in a world where cannabis wasn’t considered federally illegal and as dangerous and addictive as heroin, “I think it would be wise for carriers to support it where it was shown to be more effective and/or more safe than alternate prescription medicines.”

“I believe, and through clinical experience we have shown, that cannabis can be effective for pain that we give opiates for now. I have also had patients who have been able to substitute cannabis for opioids, thereby reducing their dependency and need for narcotic medication,” he said.

The trade association for Hawaii’s eight licensed dispensaries, HEALTH — Hawaii Educational Association for Licensed Therapeutic Healthcare — said public policy must reflect “a patients’ right to make his or her own healthcare decisions” with their physicians.

“Patients have the right to be reimbursed for any reasonable and necessary treatment recommended by their physician,” said HEALTH spokeswoman Teri Freitas Gorman.

Reimbursement of medical cannabis for workers’ comp claims has been a “hot topic for safe and legal medical cannabis stakeholders in Hawaii,” added Michael Takano, CEO of Pono Life Maui, which operates a Kahului dispensary, and chairman of HEALTH.

In 2014 New Mexico was among the first states to rule in favor of a patient, he said. To date, seven states have reimbursed patients for medical cannabis, while five others — Connecticut, Minnesota, New Jersey, New York and New Mexico — have authorized payment through appeals boards and court rulings.

On the chopping block

State legislation that would allow for medical marijuana use to combat opioid abuse in the islands is on Gov. David Ige’s veto list. Senate Bill 2407 would add to the list of medical conditions — opioid use disorders, substance use disorders and withdrawal symptoms from the treatment of those conditions — for which medical marijuana is authorized.

“We are in the middle of an ongoing opioid epidemic in this country and Hawaii is on the front lines — there are 191 drug-related deaths per year, as well as almost 500,000 active opioid prescriptions, which is enough to serve a third of our population,” said U.S. Rep. Tulsi Gabbard in a statement. “With such a stark increase in prescription opioid use and dependence, heroin and synthetic drug overdose, and emergency room visits over the last decade, we must allow legal access to medical marijuana to help prevent opioid addiction and opioid-related deaths. This legislation has the potential to save people’s lives in Hawaii.”

State Rep. John Mizuno (D, Kalihi Valley), chairman of the House Health and Human Services Committee, pledged that lawmakers will work in the next legislative session on bills that prevent insurance companies from discriminating against medical cannabis patients.

“If all insurers don’t recognize medical cannabis as legal medicine, then the 4-year-old epileptic girl has no choice. It’s going to really hurt the working families and the people who need this medicine,” Mizuno said. “How can they approve this patient for use and all of a sudden they backpedal? That’s cruel and offensive. You might overdose on opioids, but we’re not going to give you medical cannabis.”