Finessing the System

COMPARED TO MANY OTHERS, David and Fran Ritter started out on their infertility battle with economic ammunition. But it ran out fast.

Fran's job as an accountant for a big Wall Street investment firm included health coverage for one round of IVF per lifetime, which in New York can easily cost more than $10,000. But the IVF failed (the procedure succeeds less than 30 percent of the time). "Our second and third IVF cycles weren't covered," Fran says, "we paid for them ourselves."

In an unrelated move, Fran's insurance company, Aetna, announced this January it was dropping coverage of IVF and other advanced assisted reproductive techniques, which it offered as part of its basic benefits coverage. Company officials said the benefit was proving too expensive.

The Ritters live in a leafy section of Queens, where the neighborhoods were built with the brick and leaded-glass decorum of an English town. The couple guesses they spent $25,000 or more on fertility treatments, which kept them out of fancy restaurants and flashy cars, but didn't leave them broke.

"Thank goodness the stock market worked in our favor over the past few years," Davis says. "But that's not the kind of insurance policy everybody has. You can't depend on a strong, robust economy to fund your IVF cycle."

The Ritters say their infertility is a disease that should be covered like any other health problem. They dismiss the argument that having children is a personal choice rather than a medical issue.

"Just because biologically we can't produce our own offspring, why should we be treated any differently?" Fran asks, incredulous. "We desire to have a family. If a procedure exists, why shouldn't we be privy to it?"

David adds: "This is something we had no choice in. We have no control over our infertility. Insurance covers emphysema brought on by people smoking, it covers drug addiction. Why should insurance cover things people bring on themselves and not cover something that somebody else was born with? This is a disease."

The Ritters knew they'd never win by banging on Aetna's front door, so they sneaked in through bureaucratic windows and air vents. "There are certain procedures done in an IVF cycle that can be coded so that the insurance company doesn't know it's part of an IVF cycle," David explains. Doctors use a code to identify a diagnosis or procedure on the forms they submit to insurance and HMO companies. "I specifically asked our hospital, lab and infertility clinic to give us separate receipts (for each procedure) and over a period of four months slowly submitted the first bill, then the second, then the third." Eventually the company caught on. But, for awhile, it paid. And the procedures worked. The Ritters are expecting their first baby in December.

In Scarsdale, N.Y., a woman named Stephanie went to her gynecologist after she and her husband, Michael, had trouble getting pregnant. The doctor diagnosed her as infertile, and the battle with their insurance company, Oxford Health Plans, began that first day. "That diagnosis was an immediate red flag for my insurance company," Stephanie says. "They said they weren't going to pay for that visit or any subsequent visit."

Stephanie works in pharmaceutical advertising and her husband is a lawyer. They know how to work the system, and did. While the couple paid for much of their infertility treatments, they forced Oxford to pay a portion. After five years of trying to get pregnant, Stephanie gave birth to twins this year.

It was an ordeal with a happy outcome. "I think the battle with the insurance company just made the entire situation so much worse," Stephanie says. "You're struggling emotionally to accept the trouble you're having in trying to have a baby. And now here's the monolithic company putting up another barrier."