Aetna Wrongly Denies Transgender Individuals Coverage for Facial Reconstruction Surgeries, Class Action Alleges

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Three transgender women claim in a proposed class action lawsuit that Aetna Life Insurance Company has illegally refused to cover medically necessary gender-affirming facial reconstruction surgeries.

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According to the 44-page case, the plaintiffs sought the procedures to treat their diagnosed gender dysphoria—a condition characterized by clinically significant distress or impairment due to the incongruence between an individual’s gender identity and assigned sex at birth.

Although gender-affirming medical treatments, including facial feminization surgeries, are widely recognized as medically necessary treatments for gender dysphoria, Aetna denies health insurance coverage for these procedures by incorrectly characterizing them as “cosmetic,” the complaint contends.

The Aetna lawsuit accuses the insurer of discriminating against transgender plan holders, noting that members who require facial reconstructive surgery for other reasons, such as after a traumatic injury or cancer treatment, are generally subject to an individualized medical necessity determination for coverage decisions. Transgender individuals seeking facial surgeries as part of their gender transition, however, are automatically denied coverage without any individualized medical necessity evaluation, the filing alleges.

The suit says that Aetna’s allegedly discriminatory policy has forced two plaintiffs to pay thousands out of pocket for these medically necessary services. Individuals who are unable to obtain gender-affirming facial reconstruction surgery without insurance coverage, including the third plaintiff, are left to experience significant harm to their health and well-being, the case asserts.

“Because the face is one of the most visible indicators of sex, being perceived as male—both by oneself and by others—can be an extreme source of gender dysphoria,” the complaint reads. “The visible and noticeable discordance between [the plaintiffs’] genuine, lived female identities and their typically masculine facial features also places them at significant risk of discrimination, harassment, violence, and other mistreatment by neighbors, coworkers, strangers, and others who perceive them either as transgender or, incorrectly, as men who do not conform to male stereotypes.”

The lawsuit looks to represent any transgender individuals in the United States who were assigned male at birth, have been diagnosed with gender dysphoria, were referred for gender-affirming facial reconstruction surgeries by their treating providers as medically necessary treatments for gender dysphoria consistent with the World Professional Association of Transgender (WPATH) Standards of Care, and, at any time within the past four years, incurred out-of-pocket expenses and/or other compensable damages while covered by a health plan offered, underwritten, or administered by Aetna because they were denied coverage or deterred from seeking coverage for gender-affirming facial reconstruction surgeries based on Aetna’s categorical exclusion in its clinical policy bulletin on gender-affirming surgery.

The suit also seeks to cover any transgender individuals in the United States who were assigned male at birth, have been diagnosed with gender dysphoria, and who are or will be covered by a health plan offered, underwritten, or administered by Aetna that is subject to Aetna’s categorical exclusion of gender-affirming facial reconstruction surgeries in its clinical policy bulletin, and for whom gender-affirming facial reconstruction surgery is or will be a medically necessary treatment for their gender dysphoria while covered by an Aetna plan.

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