Health insurance

Employers’ health insurance must cover gender-affirming care, Court rules

Anna Lange – Photo: Transgender Legal Defense and Education Fund.

A federal court in Georgia has ruled that employers who exclude gender-affirming medical care from their health insurance coverage violate federal law.

The ruling, released Thursday, stems from a 2019 lawsuit filed by Anna Lange, a transgender woman and Houston County, Georgia, sheriff’s deputy. Lange, a 16-year veteran of the sheriff’s office, was denied coverage for gender confirmation surgery under his employee health insurance plan, due to an exclusion in department policy prohibiting coverage for transition-related medical care, including counselling, hormones and surgery.

As a result of the exclusion, Lange was forced to pay for some treatments out of pocket and forgo more expensive procedures, even though her doctors agree that such treatments are medically necessary to treat her gender dysphoria. She repeatedly asked her employer, the county, to remove the exclusion, but her requests were denied.

Lange then sued, arguing that the insurance exclusion in the county employee health plan is discriminatory and unconstitutional. Specifically, she argued that the policy discriminated against her (and other transgender people) on the basis of gender, violated the Americans with Disabilities Act, and violated her right to equal protection in under the law, as guaranteed by the Fourteenth Amendment in the United States. Constitution and the Georgian Constitution.

Chief Judge Marc Treadwell of the U.S. District Court for the Intermediate District of Georgia found that the insurance exclusion “clearly discriminates on the basis of transgender status” and thus violates prohibitions against sex discrimination. of Title VII of the Civil Rights Act of 1964 In his view, Treadwell pointed to evidence showing that the Houston County Health Care Plan, provided by Anthem Blue Cross and Blue Shield, would provide hormone therapy for menopause and breast cancer surgery to cisgender women, but does not cover exactly the same procedures if the patient is a transgender woman.

“The ultimate undisputed point is that the exclusion only applies to transgender members, and it applies to Lange because she is transgender,” Treadwell wrote, citing a U.S. Supreme Court ruling. of 2020 finding that discrimination based on gender identity or sexual orientation constitutes a form of unlawful discrimination based on sex.

“The suggestion that an employer with a single health insurance plan could fill the plan with discriminatory exclusions and avoid Title VII liability because the employer offered only one “coverage package” to all employees n ‘has no merit,” Treadwell wrote.

Treadwell also noted that in 2016, Houston County’s insurance broker, who acted as a liaison between the county and Anthem, informed the county that Anthem would no longer categorically exclude affirmation care coverage. because of the prohibitions against discrimination based on sex contained in Section 1557 of the Affordable Care Act.

“Despite Anthem’s recommendation to do so, the county chose not to accept the non-discrimination mandate,” Treadwell noted.



However, Treadwell also ruled against Lange’s claim that the exclusion violated the Americans with Disabilities Act, ruling that she failed to provide “sufficient admissible evidence” that her gender dysphoria is the result of a physical impairment.

Regarding Lange’s equal protection claims, Treadwell said those claims would be subject to litigation due to numerous disputes over whether the insurance exclusion was adopted and kept in place in the purpose of discriminating against transgender people, or whether it was kept in place because of cost. and the financial burden that would have been placed on the county. Based on information from Anthem, the specific procedure Lange is looking for — colloquially known as “bottom surgery” — costs around $25,600. However, Anthem also told the county that the cost of gender confirmation surgery can be as high as $186,000, while noting that such procedures are rare.

“Lange argues that the county’s refusal to consider an exception for Lange’s ‘gender reassignment’ surgery demonstrates discriminatory intent,” Treadwell wrote. “Sheriff Talton did not ‘believe in sex reassignment,’ and the county did not consider the cost of removing the exclusion before refusing to do so. On the other hand, since the costs of the annual plan increased by more than 17% in 2018-2019, the county may not be interested in taking action that would require it to pay more than what it was already obligated to pay under the existing conditions of the health insurance plan.… In sum, the facts are hotly disputed. The Court cannot say in law whether, under the equal protection clause, the adoption and maintenance of the exclusion was motivated by discriminatory intent.

It remains unclear whether the county will appeal Treadwell’s finding that the exclusion violates Title VII. Houston County Administrator Barry Holland told the Georgia Recorder County officials could not comment on Friday’s decision, citing “ongoing litigation.”


Lange’s legal team celebrated the decision as a partial victory, calling it a landmark decision for transgender rights that could threaten provisions that specifically exclude gender-affirming care in other places.

“The Court’s decision makes it clear that denying transgender people health care is not only immoral but also illegal,” David Brown, legal director of the Transgender Legal Defense and Education Fund, said in a statement. “An employer cannot deny health coverage to a transgender employee who needs access to life-saving medically necessary care. This decision will have a transformative impact on the quality of life for countless transgender people who live in the South.

Currently, 24 states and Washington, DC prohibit gender-affirming care exclusions in private insurance plans, while 24 states, Puerto Rico and Washington, DC have policies prohibiting gender-affirming care exclusions for Medicaid recipients.

While Treadwell has yet to decide what redress Lange will receive for being discriminated against, Lange celebrated the partial ruling as a step toward the treatment she fought for nearly five years to get.

“It is a huge relief to know that I can finally receive the medically necessary care that I have been repeatedly and unfairly denied,” she said in a statement. “I can confidently move forward in my life knowing that gender-affirming care is protected under federal law. This decision is not just a personal victory, but a tremendous step forward for all transgender Southerners seeking insurance coverage for medically necessary care.