When Your Insurance Company Says “No”: Navigating the IVF Insurance Appeal Process

IVF insurance appeal

Receiving that denial letter from your insurance company can completely dash your hopes of building your family through IVF. However, with a well-formulated appeal, you can maximize the likelihood of overturning your insurance company’s refusal to pay. Here are some things to think about when preparing for your IVF insurance appeal:

  • Determine whether your health plan is an “insurance plan” or a “self-funded plan”. While the Massachusetts infertility insurance mandate only applies to insurance plans, some employers choose to offer infertility benefits under their self-funded plans. The applicable rules and procedures also differ.
  • Understand your health plan’s infertility benefits.
  • Understand the appeals process available under your health plan.
  • Make sure you are aware of the deadlines for your appeal process.
  • Evaluate the basis for the denial.
  • Check for errors in the information upon which the insurance company based its decision. For example, a simple error in your date of birth can result in a wrongful denial based on your incorrect age.
  • Review the insurance company’s medical policy regarding IVF coverage.
  • Review any applicable laws or rules, such as those pertaining to the Massachusetts infertility mandate, to determine if the insurance company is following the legal requirements.
  • Tailor your appeal arguments to help the reviewer understand why the insurance company made a mistake–either in formulating its own guidelines or in the application of those guidelines to your situation–or why your circumstances require a deviation from the guidelines.
  • Talk to your IVF clinic’s insurance coordinator–they often have helpful insight into the process.
  • If possible, include an argument for why coverage will provide an overall financial savings to the insurance company or your employer.
  • Enclose supporting documentation from your own medical file and from reliable external sources.
  • Enclose a supporting letter from your RE.
  • Avoid arguments based on emotion; focus instead on facts, laws and science.

If you are feeling intimidated by the thought of dealing with the insurance company, check out this great guide from Fertility Within Reach to help you feel more comfortableadvocating for yourself during the insurance appeal process.  Another good resource is Fertility Within Reach’s Davina Fankhauser’s tips for making the most of your infertility insurance coverage, which recently appeared in Money Magazine.

New Hampshire lawyer Catherine Tucker