Victory! Transgender Woman Wins Health Insurance Coverage for Mammogram


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April 30 - We are thrilled to announce that we have resolved a claim on behalf of Beth Scott, a 44-year-old transgender woman in New Jersey who had been denied health insurance coverage for a mammogram. Ms. Scott 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. The plan will also allow individuals to correct the sex on their insurance records by presenting an updated ID such as a driver’s license, passport or birth certificate.

“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."

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. We are grateful for their assistance.