Premera Blue Cross Unlawfully Denies Coverage of Chest Surgery for Transgender Adolescents, Class Action Alleges

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A proposed class action lawsuit claims health insurance company Premera Blue Cross has unlawfully discriminated against transgender adolescents by refusing to cover gender-affirming surgery for insureds under the age of 18.

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The 25-page lawsuit alleges that though Premera’s policies purport to cover gender-affirming health care when medically necessary, the Washington-based insurance company excludes coverage for surgical care for insureds under the age of 18 in violation of the Affordable Care Act, which prohibits certain health care programs from discriminating on the basis of sex and age.

By excluding such coverage, the suit argues, Premera “deprives transgender youth of essential, evidence-based, and even lifesaving medical care.”

The plaintiff, a 15-year-old transgender boy who resides in Washington and is insured as a dependent, claims the insurance company refused pre-service authorization for his chest surgery and reconstruction because he is under the age of 18. The complaint says Premera also denied a subsequent appeal of this decision provided by the plaintiff’s medical providers at the Seattle Children’s Gender Clinic, which offered documentation demonstrating that he had met all the requirements for coverage of gender-affirming surgical care consistent with widely accepted clinical practice guidelines.

According to the complaint, Premera’s internal policies for similar procedures involving cisgender patients are not restricted by the insured’s age. For instance, there are no age limitations on medically necessary breast reductions for cisgender female patients or mastectomies for cisgender male insureds with gynecomastia, the filing relays.

“In other words, Premera only imposes an age restriction when the surgical care is prescribed for transgender insureds,” the lawsuit alleges.

The suit charges that the defendant’s age limitation on coverage for gender-affirming care is inconsistent with accepted medical standards and clinically ineffective for the treatment of gender dysphoria.

“Being transgender is not a medical condition to be treated or cured,” the case describes. “But gender dysphoria—the clinically significant distress that some transgender people experience as a result of the incongruence between their gender identity and sex assigned at birth—is a serious medical condition.”

The plaintiff, who has been diagnosed with gender dysphoria, was denied coverage for surgical care based on Premera’s judgment that “gender-affirming surgery can never be medically necessary for youth under the age of 18,” the complaint says. As a result, the boy and his parents have been forced to pay for the surgery out-of-pocket, the filing states.

Per the case, the plaintiff has suffered “stigmatization, humiliation, and a loss of dignity because of [Premera’s] targeted discrimination against transgender youth, which wrongly deems their health care needs as unworthy of equal coverage.”

The lawsuit looks to represent anyone who has been, is or will be a participant or beneficiary in Premera non-grandfathered “group health plans” (whether insured or administered by Premera) who required, requires or will require gender-affirming chest surgery to treat a diagnosis of gender dysphoria, and who was denied pre-authorization or coverage of required surgical care because they were or are under the age of 18.

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