Your Insurance Denied IVF Coverage. That Denial May Be Illegal.

A denial should identify the reasons for the decision and the applicable review process. Read it together with the plan documents and preserve the date received.

Some denials can be challenged under plan terms, applicable coverage mandates, or nondiscrimination requirements. The availability of an appeal or lawsuit depends on the plan and the basis for denial.

California’s new IVF coverage law: SB 729

If you are covered by a fully insured large-group health plan in California, the rules changed on January 1, 2026. Under SB 729, plans issued, amended, or renewed on or after that date must cover:

• Diagnosis and treatment of infertility
• IVF, including up to three completed egg retrievals and unlimited embryo transfers
• Medically necessary fertility preservation, such as egg or sperm freezing before cancer treatment
• Related medications, monitoring, and lab services, with cost-sharing no worse than for other benefits

The law also redefines infertility to include anyone unable to reproduce without medical intervention, whether alone or with a partner. Single people, same-sex couples, and people with a medical reason they cannot conceive or carry are covered on the same footing as anyone else.

Two important limits. SB 729 applies to fully insured plans regulated by California’s Department of Managed Health Care or Department of Insurance. It does not apply to self-funded employer plans, which cover roughly half of American workers, or to Medi-Cal. And it takes effect on your plan’s renewal date, so a plan renewing in July 2026 was not required to comply until then.

Review the denial against the plan’s eligibility rules, effective dates, and applicable coverage requirements. A California connection alone does not establish that a particular plan must cover IVF.

The definition problem

Eligibility definitions. A policy’s definition of infertility may affect single patients and LGBTQ couples differently. Whether that difference is unlawful requires a review of the plan and applicable law.

Many plans define infertility as the failure to conceive after twelve months of unprotected heterosexual intercourse, or six months if over 35. To access fertility benefits, you must first meet that definition.

A single woman cannot satisfy it. A woman in a same-sex relationship cannot. A gay male couple cannot. Not because of any medical difference, but because the plan defined the qualifying condition in terms of a sexual relationship they do not have.

A requirement to pay for attempts at conception before qualifying for benefits may impose different burdens on different patients. Preserve the written criteria and evidence of how they were applied.

The suggestions in this section are non-exhaustive and informational, not directives or legal advice for your situation. Consult a lawyer to develop an appropriate plan. Before any medical or specimen-handling decision, coordinate with your treating doctor and seek immediate medical advice; do not delay urgent care. For each item, request records and explanations in writing, retain original communications, and seek written confirmation of calls. Keep all lawfully obtained documents organized chronologically in electronic form and as hard copies; preserve original audio and digital files as well.

If your denial rests on a definition you cannot meet because of who you are or who your partner is, that is worth examining closely.

Other common grounds for denial, and what to do with them

These are non-exhaustive informational suggestions, not directives or legal advice for your situation. Consult a lawyer to develop an appropriate plan. Before any medical or specimen-handling decision, coordinate with your treating doctor and seek immediate medical advice; do not delay urgent care.

“Not medically necessary.” Applied to IVF where the insurer says less aggressive treatment should be tried first, or to PGT, or to a specific protocol. This is a clinical judgment by a reviewer who has never seen you, and it is rebuttable with a letter of medical necessity addressing the plan’s stated criteria point by point.

“Experimental or investigational.” Applied to PGT, certain add-ons, and sometimes egg freezing for medical reasons.

Fertility preservation before treatment that may impair fertility can be time-sensitive. Ask the treating team and plan about urgent clinical coordination and expedited review without delaying necessary cancer care.

Lifetime maximums and cycle limits applied incorrectly.

Network and exclusion issues, including denials for using the only qualified clinic within reasonable distance.

Surrogacy and gestational carrier exclusions applied to patients with a medical reason they cannot carry.

Transgender patients denied fertility preservation before gender-affirming care.

ERISA: why the appeal you file yourself matters so much

The suggestions in this section are non-exhaustive and informational, not directives or legal advice for your situation. Consult a lawyer to develop an appropriate plan. Before any medical or specimen-handling decision, coordinate with your treating doctor and seek immediate medical advice; do not delay urgent care. For each item, request records and explanations in writing, retain original communications, and seek written confirmation of calls. Keep all lawfully obtained documents organized chronologically in electronic form and as hard copies; preserve original audio and digital files as well.

For some benefit claims, later judicial review may be limited largely to the administrative record. Discuss the appropriate medical evidence, arguments, submission method, and deadlines with counsel and your treating doctor before deciding how to prepare an appeal.

In most ERISA cases a court reviews only the evidence in front of the plan administrator when it made its final decision. New evidence introduced later is often excluded. The appeal you file yourself, before any lawyer is involved, may determine the outcome permanently.

Practical consequences:

• Ask counsel promptly whether an internal appeal is required and how to preserve the applicable deadline.
• Discuss with counsel and your doctor which medical records, clinician explanations, professional guidance, and benefit information should accompany an appeal. Consider a written submission using the required process and retain proof of delivery.
• Request the plan documents in writing. You are entitled to the Summary Plan Description, the full plan document, the claims and appeals procedures, and the specific clinical criteria used to deny your claim. Plans that fail to produce these can face daily penalties.
• Do not miss an appeal deadline. Insurance appeals and administrative complaints can be due within months, and urgent treatment may require expedited review. A lawsuit deadline can be as short as one year, or shorter depending on the claim and applicable rules. Speak with a lawyer promptly to review the denial, plan documents, required appeals, and filing deadlines. Do not assume that informal discussions with the insurer or employer preserve your rights.
• Get the denial in writing with the specific reason and plan language relied on.
• Ask counsel or the plan administrator in writing whether external review is available and what procedure and deadline apply.

If your employer is a government entity or a church plan, ERISA may not apply and different, often better, rules govern.

When a benefit denial is also employment discrimination

Fertility benefits are compensation. A benefit structured so some employees can use it and others cannot, based on a protected characteristic, is a pay problem, not only an insurance problem.

Title VII. Discrimination based on sexual orientation or gender identity may be a form of sex discrimination. A benefit definition that excludes same-sex couples by design is squarely within this framework.

The Pregnancy Discrimination Act, which has been applied to infertility treatment in the employment context.

The Americans with Disabilities Act. Reproduction is a major life activity, and infertility has been treated as a disability under the reasoning of some courts.

California’s Fair Employment and Housing Act, which is broader than federal law and covers sex, gender identity, gender expression, sexual orientation, marital status, and medical condition.

Pay equity statutes, where the benefit disparity operates as a compensation disparity.

An employer’s potential responsibility depends on its role in selecting, administering, or applying the benefit policy. The plan documents and decision-making records matter.

What to collect right now

The suggestions in this section are non-exhaustive and informational, not directives or legal advice for your situation. Consult a lawyer to develop an appropriate plan. Before any medical or specimen-handling decision, coordinate with your treating doctor and seek immediate medical advice; do not delay urgent care. For each item, request records and explanations in writing, retain original communications, and seek written confirmation of calls. Keep all lawfully obtained documents organized chronologically in electronic form and as hard copies; preserve original audio and digital files as well.

• Consider retaining written copies of the denial letter and every prior communication.
• Consider retaining written copies of the Summary Plan Description and full plan document, requested in writing.
• Consider retaining written copies of the exact definition of infertility your plan uses.
• Consider retaining written copies of the clinical criteria used to deny, requested in writing.
• Consider retaining written copies of your physician’s records and a letter of medical necessity.
• A written calendar of each appeal deadline, reviewed promptly with counsel.
• Consider retaining written copies of your benefits enrollment materials and anything the employer said when marketing the benefit.

Only download, copy, forward, or remove materials from an employer’s email accounts, devices, or systems if you are lawfully authorized and doing so complies with all applicable laws, employer policies, confidentiality obligations, and access restrictions. Do not access someone else’s account, bypass restrictions, or take information you are not entitled to possess. If uncertain, consult a lawyer before acting; counsel can evaluate a lawful records request or other appropriate process.

• Your own dated written observations of how similarly situated coworkers were treated, without accessing their confidential records or accounts.

Send us your denial letter

Melmed Law Group is a plaintiff-side litigation firm with more than 15 attorneys handling hundreds of active matters. We do not represent clinics, laboratories, or insurers. The initial consultation is by phone. If a second consultation is needed, we conduct it by Zoom videoconference. In-person meetings are always available at the client’s request.

If your fertility benefits were denied, contact Melmed Law Group for a free, confidential consultation. Call (310) 742-0882 or request a consultation, and ask how to provide the denial and plan documents securely. Seek review promptly because appeal and filing deadlines may be short.

Related reading: California IVF Malpractice and Embryo Loss Lawyers | Does California’s SB 729 Cover IVF for Single Women and LGBTQ Couples? | IVF Discrimination at Work: Leave, Retaliation, and Your Rights

Sources: California SB 729 (2024), infertility and fertility services coverage | 42 U.S.C. section 18116 (ACA Section 1557 nondiscrimination) | 29 U.S.C. section 1133 (ERISA claims procedure)

Attorney advertising. This article is general information, not legal advice, and does not create an attorney-client relationship. Prior results do not guarantee a similar outcome.