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December 02, 2022

TPA Sued for Failure to Cover Gender Affirming Care

The family of a teen seeking gender-affirming care through a Catholic Health Initiatives employer-funded health plan had sued the plan’s third-party administrator (TPA) BCBS of Illinois in November 2020 for refusal to cover gender-affirming treatment.  On November 9, a Federal District Court Judge in Washington State certified the case as a class action.  The plaintiffs are seeking to force the plan’s TPA, BCBS Illinois, to pay for the treatment regardless of the plan benefits excluding such care. 

Should this case proceed and a ruling in the plaintiffs’ favor be issued by the Court in Washington State, a precedent will be set allowing self-funded plan beneficiaries to force TPAs to cover care the self-funded health plan does not cover. The Plaintiffs are seeking to force the TPA (that is legally obligated to administer the plan as written) to approve or cover the care based on antidiscrimination clauses or interpretations by HHS of section 1557 of the ACA. On November 23, BCBS Illinois filed a Petition with the Ninth Circuit to appeal the class certification among other relief (Case No.  22-80136)

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