Insurance Company Agrees to Cover Transgender N.J. Woman's Mammogram Claim

A transgender New Jersey woman has reached a settlement with her health insurance company that had declined to cover a sex-specific procedure that had been deemed medically necessary.

Beth Scott underwent a mammogram in June 2010 at her doctor's recommendation. Aetna declined to cover the procedure because Scott's policy had a "Sex Reassignment Exclusion" that did not include treatments, drugs, services or supplies "related to changing sex or sexual characteristics." Scott subsequently appealed the decision, but the company denied it.

In the settlement that the Transgender Legal Defense and Education Fund announced on Monday, Aetna agreed to cover the mammogram and any future procedures that Scott may have to undergo. The company agreed that the Sex-Reassignment Exclusion clause in her policy only applies to treatments, drugs, services or supplies specifically used to change a patient's sex or sex characteristics.

Aetna also formally apologized to Scott.

"In reviewing [Scott's] mammogram claim and plan documents, we have determined that the eligibility of the claim and the plan benefits were misinterpreted," wrote Shelly Ferensic, vice president of Aetna Service Operations, in a March 13 letter to Scott's lawyer, Carmine D. Boccuzzi, Jr. "We also verified that routine and medically necessary mammograms are not automatically excluded just because a plan excludes transgender surgery. Therefore, based upon clinical information, the claim should have been paid according to her plan benefits, as we consider this to be a routine test that is covered under the plan."

Scott said that the settlement is about fairness.

"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," she said in a TLDEF press release.

This settlement underscores the challenges many trans people face when they submit claims for sex-specific procedures to their health insurance companies.

Lina Kok, a trans woman from North Carolina, reached a settlement with Prudential last fall after it denied a short-term disability claim she filed in Nov. 2010 after she underwent reconstructive facial feminization surgery.

The California Court of Appeals ruled in 1978 that the state's Medicaid program must cover sex-reassignment surgery because it is not a cosmetic procedure. A New Jersey judge in 1992 ruled that the state's Medicaid program must also cover the procedure.

The Minnesota Supreme Court in 1977 struck down their state Medicaid's blanket exclusion for SRS, but lawmakers subsequently reinstated it in 2005. The program still covers hormones and therapies for trans recipients.

The World Professional Association for Transgender Health acknowledges facial plastic reconstruction and other sex-reassignment procedures are "medically necessary" to treat Gender Identity Disorder. The U.S. Tax Court upheld this standard in 2010 with its ruling that SRS and other trans-specific surgical procedures are tax deductible.

TLDEF staff attorney Noah Lewis noted to EDGE that insurance companies continue to move to cover sex-specific treatments and procedures that trans patients' doctors deem medically necessary.

"As long as they are in place, they have to be interpreted narrowly and not be used to deny transgender people care that is provided to everyone else," he said.