April 30, 2012

Transgender Woman Wins Health Insurance Coverage for Mammogram

Insurance Company Overturns Previous Claim Denial and Agrees to Limit Scope of Transgender Health Care Exclusion

New York, NY – Transgender Legal Defense & Education Fund (TLDEF) today announced that it has resolved a claim on behalf of a transgender woman who had been denied health insurance coverage for a mammogram.  Beth Scott, a 44-year-old New Jersey resident, underwent the mammogram in June 2010 at her doctor’s recommendation. Aetna denied coverage for the mammogram on the grounds that it fell under her policy’s exclusion for treatments “related to changing sex.” As a transgender woman, Ms. Scott was assigned male at birth and developed breasts after undergoing hormone therapy.  Aetna refused to alter its position throughout the lengthy appeals process.

TLDEF intervened and argued that Aetna’s interpretation of the policy exclusion was overbroad and that it should apply only to treatments prescribed to change an individual’s sex characteristics.  Because a mammogram is a procedure that has nothing to do with changing sex characteristics, Ms. Scott’s mammogram should have been covered.  Aetna’s interpretation could have led to the continued denial of claims for medically necessary care for transgender patients, including treatment for conditions such as breast cancer.

Aetna reversed its position and paid for Ms. Scott’s mammogram in full.  It agreed that the policy exclusion for transgender health care will apply only to treatments prescribed to change an individual’s sex characteristics, and not to any other medically necessary care.  Additionally, Ms. Scott secured changes to the health plan ensuring that transgender people can access all necessary sex-specific care, such as prostate exams and gynecological care, regardless of whether they are categorized as male or female in insurance records. Many transgender people have claims rejected when an insurance company asserts that the procedure is not covered because it does not match the sex listed in the policyholder’s records.

“I was denied access to the same health care benefits that my co-workers receive,” Ms. Scott said.  "While I’m hopeful that my employer will soon eliminate the transgender health exclusion altogether, I'm relieved to know that the existing exclusion can no longer be used to unfairly deny me other needed health care like a cancer screening just because I’m transgender."

Exclusions for transgender health care such as hormones and surgery exist in most health insurance plans.  These exclusions unfairly force transgender policyholders to pay out-of-pocket for medically necessary care. Often, as in Ms. Scott’s case, insurance companies also use such exclusions to deny transgender policyholders coverage for other medically necessary care that is in fact covered under the plan.

“Transgender people should have their health care needs covered by insurance just like everyone else. The trend is that employers are increasingly removing these harmful exclusions for transgender health care," said TLDEF staff attorney Noah Lewis.  "But as long as exclusions remain in place, Ms. Scott's case makes clear that they cannot be used to deny other medically necessary care simply because someone is transgender."

Steven Goldstein, Chair and CEO of Garden State Equality, New Jersey’s largest lesbian, gay, bisexual and transgender civil rights organization, celebrated the announcement.  He stated, “Even in states like New Jersey with the country’s best laws for transgender people, some insurance companies still discriminate against our transgender sisters and brothers by denying them access to health care.  This victory is a huge step toward ending that discrimination.”

Barbra Casbar Siperstein, Director of the Gender Rights Advocacy Association of New Jersey, also welcomed the victory.  She noted, "This important case spotlights the pervasive institutionalized discrimination by health insurance companies denying basic medically necessary coverage to their transgender customers."  Ms. Siperstein added, "As a New Jersey small business owner who provides insurance coverage for my employees, I find it intolerable that the same coverage that my employees get has been denied to me solely because I am transgender."

In addition to TLDEF, the legal team representing Ms. Scott included Carmine Boccuzzi, Luke A. Barefoot, Scott Thompson, Nathan Horst and Lina Bensman of Cleary Gottlieb Steen & Hamilton LLP.


Transgender Legal Defense & Education Fund is committed to ending discrimination based upon gender identity and expression, and to achieving equality for transgender people through public education, test-case litigation, direct legal services, community organizing and public policy efforts.