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Do you need help with insurance coverage or information on treatment costs?

This page is designed to help you deal with medical insurance for infertility related treatment.

Are you covered?
What happens if your claim is denied?
From an employers point of view
If you find that you're not covered for infertility treatment by the health insurance you have, (see www.resolve.org's ) our creative financing page will give you some practical ways to reduce the overall cost of treatment.

Are you covered?

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 policy.

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 undergo.


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 member

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 excluded.
(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
infertility coverage.

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 medical
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

Recommended treatment

Probability for each type of treatment

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 caused by
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.



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