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.