Max and Sarah

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Date Submitted: 09/13/2011 06:13 PM

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Chantina Powers

Unit 5 essay


June 21, 2011

1. Max and Sarah have medical insurance through Max’s employer. The insurance company, Sunny Insurance, provides basic coverage for all employees. The couple has been trying to have a child naturally for a very long time but have not been successful so are trying infertility treatments. Max has a low sperm count and Sarah also has issues. They went through infertility treatment in the past and have one child as a result. They would like a second child. They tried basic insemination but it failed. Sunny Insurance paid for that procedure without any problem. Their physician recommended a more complex and expensive process called Vision I. Max and Sarah went through the Vision I process and submitted the bill to Sunny Insurance, which rejected the bill. The insurance company provided to Max and Sarah the section of their insurance contract that says:

If a covered individual or family member incurs outpatient expenses resulting from an illness or an injury, those expenses charged…..are covered expenses under this specific provision.

The Company also included another section of the insurance contract with the employer, which provided a definition of illness as “any sickness occurring to a covered individual or covered family member which does not arise out of or in the course of the employment of the primary insured individual."

Sunny then denied the claim saying that this claim did not arise out of an illness for Mary Jane.

How would you evaluate the decision of the insurance company? Is infertility an illness? How would you define illness in general and in this case?

There are a lot of factors that come into play with this scenario, first what medical issues does Sarah have? If she had something like endometriosis then I would consider that a medical problem that is covered under the insurance and would be looked at as a disease that is not preventable. If Sarah just has an irregular cycle then...