Your insurer has denied you coverage for gender-affirming medical care. You believe this denial is wrong or a mistake, but you’re not sure what your rights are or who can help. What’s your next step?

If you have individual coverage through the Marketplace or direct with an insurer, or you’re insured through a workplace-provided plan, the Oregon Division of Financial Regulation (DFR) might be able to help. The Department of Consumer and Business Services (DCBS) houses DFR, the state’s regulatory agency for all insurance services that are individual plans, or employer-provided and not self-insured. (Your employer likely isn’t self-insured unless it’s a very large company, such as Intel.)  DFR does not regulate Medicaid or Medicare. 

DFR has helped rectify insurance issues for LGBTQ2SIA+ Oregonians, and it’s a free resource through which you can submit complaints about insurance denials, or other concerns. If DFR finds that insurance denial to be against Oregon law, you’ll get results.

But the process doesn’t necessarily end there—DFR will often then prompt the insurer to review other cases in which they denied that same coverage to other consumers. For example, when DFR recently found that a major health insurer had erroneously denied a trans person facial feminization surgery (FFS), it ordered a review of similar cases from the same insurer. The insurer found six other instances in the last year of wrongful denials for FFS, and reversed those denials.  It also fixed an error in its system that had caused the denials.

Because one person submitted a complaint for FFS denial, seven trans people got the medical care they need. And in the future, fewer trans Oregonians will experience the pain that comes with being denied gender-affirming care.

“Once we identify the problem with one insurer, we start looking for the same problem at other insurers,” says Tashia Sizemore, a compliance manager at DFR. “So if we identify problematic form language insurers are using to deny coverage, then that becomes a target not just for them but for every other insurer on the market.” 

It’s important to note that DFR doesn’t only focus on medical insurance, but all types of insurance. LGBTQ2SIA+ Oregonians are adversely impacted across different insurance services—such as a lack of inclusivity on life insurance forms—and DFR has helped rectify these issues as well.

If you believe you’ve been wrongly denied insurance coverage, you can file a complaint via the DFR website. You’ll also find contact info for who to call if you have questions, and other helpful info.

You should get a response from DFR within 60 days of filing your complaint, though the process can occasionally take longer. Should DFR need more time to investigate your complaint, you’ll be contacted with an update.

If DFR finds your complaint to be valid, and the denial was in violation of the contract or insurance code, it will direct your insurer to correct the initial denial and provide coverage.

In addition to investigating complaints, DFR also does outreach work, including working with LGBTQ2SIA+ community groups to educate folks about their insurance rights. If you’d like to work with DFR, you can reach them at outreach.dfr@oregon.gov.