I’m not married: Does my health insurance cover infertility services?

Posted by: Jill Morrison at November 16, 2011
Category: Health Insurance

Lisa Green’s* insurance benefits book listed “artificial insemination” under covered services. It did not say “but only for married people.” Yet when her doctor recommended artificial insemination, the insurer denied her claim because she was not married.

In its communications to Lisa, the insurer claimed that because the benefits book said “cost of donor sperm” was not covered, a woman using donor sperm (e.g., sperm from anyone other than her spouse) was not entitled to artificial insemination coverage.

Lisa looked again at her benefits book. There was “artificial insemination” under covered services. There was “cost of donor sperm” under services that were not covered. But Lisa did not have any cost for donor sperm, since she was using her life partner’s sperm. And it did not seem like a narrow exclusion for the “cost of donor sperm” should affect her coverage for the artificial insemination procedure itself.

Through the National Women’s Law Center, Lisa learned that because her insurance was a federal employee HMO, she had more than just the benefits book language on her side. HMOs that cover federal employees are required to cover “artificial insemination with either the husband’s or donor sperm.”

Lisa appealed the coverage denial, writing that just because a plan does not cover the cost of donor sperm does not mean that it can exclude any procedures that use donor sperm. She won, and the insurer covered her treatment.

Lessons learned:

If you are a federal employee with an Federal Employees Health Benefits (FEHB) HMO, your plan is required to cover family planning services, which includes artificial insemination. (Your plan is not required to cover the cost of donor sperm or in vitro procedures).
Even if you do not have a federal employee HMO, if your benefits book says it covers infertility treatment, you might be able to hold them to that language. Read carefully. If the benefits book does not say you must be married, but the company denies your claim, appeal the decision.

*Lisa Green is a pseudonym to protect her privacy.

Jill Morrison is Senior Counsel at the National Women's Law Center.