Transgender teenager’s health insurance violated ACA by denying coverage, lawsuit alleges
An insurance company violated the Affordable Care Act by failing to cover gender-affirming health care for a transgender teenager, a Bremerton family’s lawsuit alleges.
Pattie Pritchard sued Blue Cross Blue Shield of Illinois on behalf of her 15-year-old son, identified in court records by the initials C.P.
“My son needs the medical care that will allow him to live, be healthy, and to thrive,” Pritchard said in a news release. “However, because he is transgender, I have to fight and jump through hoops for him to have access to the care that he needs, is legally entitled to and that he deserves. This denial also sends a message to my son and all transgender people, that their health care needs aren’t real or they’re not worthy of care. I won’t accept that.”
Pritchard works for St. Michael Medical Center. She and C.P. are both insured through her employment there. The facility is part of the Catholic Health Initiatives Franciscan Health System (known as CommonSpirit Health after a 2019 merger).
“BCBSIL cannot hide behind a defense that it was ‘just following orders’ when Pritchard’s employer told BCBSIL to apply the illegal exclusion,” one of the family’s attorneys, Eleanor Hamburger of Sirianni Youtz Spoonemore Hamburger, said in the release. “BCBSIL has a separate legal, contractual and fiduciary duty to C.P. and others in the health plans it administers, to comply with the anti-discrimination law.”
A Blue Cross Blue Shield of Illinois spokesperson said she could not comment on pending litigation. CHI Franciscan, which is not a party to the lawsuit, also declined to comment.
The complaint, filed Nov. 23 in U.S. District Court in Tacoma, seeks unspecified damages.
It says C.P.’s parents have more than $10,000 in out-of-pocket expenses.
“Although it is a heavy burden on our family, we are lucky that we can pay for C.P.’s critical health care while we fight, but I shudder to think of the families that cannot,” Pritchard said in the news release. “What is a family who cannot afford this very expensive care for their child supposed to do? This is a matter of life and death for many transgender people and children, and I hate to think of the difficult and scary decisions families are forced to make; it’s not fair, and it’s not right.”
The lawsuit gives this account of what happened:
C.P. has been diagnosed with gender dysphoria, which is “a feeling of clinically significant stress and discomfort” a person experiences when there’s “an incongruence between their gender identity and sex assigned at birth,” the lawsuit says.
C.P. started getting “gender-affirming care” three years ago. That can include counseling, hormone replacement therapy, surgical care or other treatment. The insurance company covered some of his treatment, but other procedures weren’t covered, even though health care providers found them medically necessary to treat C.P.
“... BCBSIL has administered the Plan’s Exclusion of all treatment that BCBSIL construes to be ‘for, or leading to, gender reassignment surgery.’” the lawsuit says. “BCBSIL continues to do so, to date.”
It goes on to say: “BCBSIL agreed to administer the Exclusion in the Plan for Catholic Health Initiatives/CommonSpirit Health, even though BCBSIL knew that Plan enrollees with gender dysphoria needed medical treatment for their condition. It did so despite the nondiscrimination assurances BCBSIL provided to the federal government and to the Plan’s Enrollees.”
Some of that same care is covered without problems for patients who are not transgender, the lawsuit alleges.
“The law is clear, Blue Cross Blue Shield of Illinois cannot deny C.P., or any transgender person, the health care that he needs,” one of the family’s attorneys, Omar Gonzalez-Pagan with Lambda Legal, said in the news release. “Section 1557 of the ACA expressly prohibits categorical bans on gender-affirming care because it is discrimination on the basis of sex, plain and simple.”
The lawsuit notes that major medical organizations have opposed such exclusions.
“In the past, public and private health administrators and payors excluded coverage for medically necessary treatment of gender dysphoria on the erroneous assumption that such treatments were cosmetic or experimental,” the lawsuit says. “Today, the medical consensus recognizes that exclusions of treatment for gender dysphoria on those grounds have no basis in medical science.”
