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INSURANCE
Frequently Asked Questions
The following questions and answers are provided for general purposes only. They do not constitute legal advice nor do they create an attorney-client relationship between Ballard, Desai, Bush-Joseph & Horwich and the reader. Persons seeking legal advice should individually consult with a qualified attorney who has had the opportunity to review the relevant facts of their particular situation.
Since
Illinois has a law that requires coverage for infertility treatment, why
is my insurance denying coverage of my treatment?
What does self-insured mean?
How can I find out if my
employer is self-insured or not?
I think my employer is not
self-insured, and is required to provide coverage under the Illinois Family
Building Act, but my claims are being denied.
My employer is not headquartered
in another state, but they say they are not required to follow the Illinois
law because the insurance policy is not delivered in Illinois.
What if I choose my company's
HMO option?
I have already done 4 IVF
cycles. If I switch employers and insurance plans, will more cycles be
covered?
My employer is self-insured,
and excludes coverage for infertility treatment. Since they are not covered
by the Illinois law, am I out of luck?
How do I fight my employer
or insurance company about insurance claim denials?
Since
Illinois has a law that requires coverage for infertility treatment, why
is my insurance denying coverage of my treatment?
The Illinois law, called the Family Building Act or "FBA", provides for
coverage of infertility treatment by employers with 25 or more employees
headquartered in Illinois. However, if the employer company is self-insured
for medical insurance, then the Family Building Act does not apply. [back]
What
does self-insured mean?
Most large employers like Motorola, Sears, and Ameritech are self-insured. It means that the company pools its own money for insurance claims and hires a third party administrator, like Blue Cross or Cigna, to review and pay out or deny the claims. A company that is not self-insured pays premiums to an insurance company for medical insurance. [back]
How
can I find out if my employer is self-insured or not?
Ask your Human Resources Department, review the summary of benefits booklet or call the insurance company. [back]
I
think my employer is not self-insured and is required to provide coverage
under the Illinois Family Building Act, but my claims are being denied.
Is your company's headquarters in Illinois? The employer is required to follow the insurance laws of the state where the company is headquartered. If your company's headquarters are in Minnesota, the company is not required to follow Illinois law, and Minnesota is not one of the dozen or so states that require coverage for infertility treatment. [back]
My
employer is not headquartered in another state, but they say they are
not required to follow the Illinois law because the insurance policy is
not delivered in Illinois.
Unfortunately, some companies are getting around the Illinois law by having their insurance policies delivered to trusts that are set up in other states, like Alabama, that do not have insurance mandates. The Illinois Department of Insurance has taken the position that this is a legitimate practice, and that they have no control over companies that do this. [back]
What
if I choose my company's HMO option?
True HMO's in Illinois follow the Illinois law. Therefore, even if your employer is self-insured, if the company has an HMO option, you should consider enrolling during the next open enrollment period because you will be covered for infertility treatment. You will be limited, however, to the HMO's doctors. [back]
I
have already done 4 IVF cycles. If I switch employers and insurance plans,
will more cycles be covered?
The Illinois Family Building Act provides for coverage of 4 completed oocyte retrievals, and if a baby is born as a result, then an additional 2 cycles. The limitations are for the lifetime of the individual. Therefore, changing insurance plans or employers will not change the number of cycles covered.
[back]
My
employer is self-insured, and excludes coverage for infertility treatment.
Since they are not covered by the Illinois law, am I out of luck?
We have successfully argued in a number of cases that limitation or exclusion of infertility benefits violates the Americans with Disabilities Act or "ADA" and other federal laws. The ADA provides that companies cannot discriminate against people with disabilities. Infertility has been held to be a disability under the ADA by federal courts in Illinois, and the United States Supreme Court. The Equal Employment Opportunity Commission in New York also issued a determination on April 27, 1999, that exclusion of medically necessary treatments for infertility violates the ADA and Title VII. [back]
How
do I fight my employer or insurance company about insurance claim denials?
Resolve of Illinois has a package available for a minimal fee to help
you fight insurance claim denials which includes sample letters. Call
Resolve at 800-395-5522 for an order form. Whether you decide to fight
for coverage on your own or with the help of a lawyer, remember there
are time limits for appealing the denial of claims and for filing charges
with the EEOC, which is one of the steps required before a lawsuit can
be filed. So act quickly to protect your rights. [back]
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