Question
What is the name of your state? PA
Is it legal for a health plan to provide coverage for a particular medical condition for some participants and not others based on another medical condition?
Example:
My wifes company health plan has a lifetime benefit for infertility services including IVF of $5000. She was diagnosed with cancer 5 years ago and had a hysterectomy, but maintains functioning ovaries. Therefore the use of a gestational carrier will be required to complete the IVF procedure.
She was denied any of this $5000 benefit due to not having a uterus. A procedures such as egg retrieval that could still be performed on her was denied. This same procedure would be acceptable had she had a uterus to reimplant a resulting embryo or for anyone else having a uterus.
It seems like this could be some form of discrimination. I wouldn't expect a plan to cover the expenses of a Gestational carrier, but procedures limited to the plan participant that are covered on other individuals in the plan does not seem fair.
Any comments or legal opinions would be appreciated.
Answer
If your wife does not meet the definition of an eligible participant for this benefit, it is not illegal discrimination to deny the benefit.