Figuring out whether your medical
insurance coverage includes benefits for infertility can often
be confusing, frustrating and disappointing. Most states have
no legislation requiring insurance companies or employers
to offer coverage for infertility treatment. Fortunately,
Hawaii requires coverage of one infertility treatment per
Before you undertake any type
of infertility treatment, we recommend that you contact your
insurance company to determine for what types of infertility
treatment you are covered.
Infertility treatment is a dynamic field - new treatments
are being discovered very frequently. Many types of infertility
treatment are expensive - they also vary widely from clinic
to clinic. Perhaps the most important thing to remember is
that most, if not all, insurance companies require that you
obtain written pre-approval for treatment. Even if your company
does not, we recommend that you get a written pre-approval
that is as specific as possible to the treatment you will
What happens if your claim is denied?
"Before we started our IVF treatment, we followed all
our insurance company's rules. We went to our clinic to find
out what treatment they would be giving me. We had them submit
it to the insurance company requesting a pre-approval. Eventually,
after talking several times to a supervisor on the telephone,
we received a verbal approval on the phone. Some weeks later,
we received the written authorization. Our Reproductive endocrinologist
prescribed leading edge drugs that had recently been proven
more effective than the "standard" treatment. When
it cam time to submit the claim to the insurance company,
we found that they would not cover these leading edge drugs
- we ended up paying almost $5,000 out of our own pocket which
we had expected the insurance plan to pay for."--RESOLVE
So, even if you do follow all
the rules, you still may end up in trouble. Here are some
simple steps to help you deal with your insurance company
if they deny your claim.
1. Read and understand your
policy. Learn not only what is included, but what is specifically
(i.e. in vitro fertilization, donor insemination).
Read all policies available to you at times of open enrollment.
Find out when your employer renews all insurance programs.
Submit requests to your human resources department to offer
a policy which is inclusive of
2. Writing and calling.
Get everything from your company in writing and SAVE IT.
When writing to your company, send the letter registered or
certified mail, so that someone has to
sign for it. KEEP COPIES.
When calling your company, keep notes of the conversation,
dates, times, name of the person and
his or her department, Follow up the call with a letter to
the person recapping your understandings
of the conversation and asking if they understood the same
things. KEEP COPIES.
3. Obtain copies of all letters
sent from your Doctor to the company and perhaps copies of
records relating to the condition. If you need to forward
any of these, KEEP COPIES.
4. Doctors Correspondence -
ask that the doctor state:
What's wrong - specific disease
Possible treatment range
Probability for each type of
Possible outcome with no treatment
which might include issues of life disruption often
caused by the stresses of infertility.
5. You might want to keep a
record of time lost from your job due to medical problems
endometriosis, adhesions, or from depression. But be cautious
how you use this.
6. Save all bills relating
to infertility, including counseling if related to your infertility.
7. If a claim is denied, ask
for a specific citation in the policy used to justify the
denial. DO NOT accept the reviewers "understanding"
or "interpretation" of the policy. ask for the legal
language used for the denial. If the company cannot produce
this, you have a fighting chance.
8. At the same time, make an appointment with your employer's
claims rep. Take your claims and all correspondence and try
to get them involved. If they think the claim should be paid,
it may be.
9. Register a complaint with
the State Department of Commerce and Consumer Affairs.
This usually requires a copy of all prior correspondence and
a letter explaining the problem. Be sure to include a statement
noting that your physician recommends the procedure (this
should be clearly stated in the original physician letter
to the insurance company)
10. Some companies may be open
to the possibility of a negotiation of your benefits, perhaps
including a one-time shot at one or more cycles of an assisted
reproductive technology, particularly if you have tubal disease
or male factor infertility.
Companies who are self-insured (ERISA), are more open to negotiation
on a case by case situation.