OUT-OF-POCKET EXPENSE SUBMISSION

Goidel et al. v Aetna Life Insurance Company
U.S. District Court, Southern District of New York
Case No. 1:21-cv-07619 (VSB)

If (1) Aetna denied your request for precertification or your claim for one of an agreed-upon set of qualifying artificial insemination (intracervical insemination (“ICI”) or intrauterine insemination (“IUI”)) or in vitro fertilization (“IVF”) procedures, or if Aetna would have denied your request for coverage for artificial insemination that you underwent, between September 1, 2017 and Execution date and you were in an Eligible LBGTQ+ Relationship as described in the Settlement Notice, (2) you have not requested exclusion from the settlement, and (3) you incurred out-of-pocket expenses arising from Defendant’s denial or anticipated denial of your infertility coverage request that exceed your Default Dollars for Benefits amount or your Proof of Greater Covered Care award, you may be eligible for additional compensation and should complete this Out-of-Pocket Expense Submission.

Examples of potentially eligible out-of-pocket expenses include: cycles of IUI insemination; consultations with medical professionals regarding IUI services; vials of donor sperm; ultrasound and bloodwork monitoring in connection with IUI cycles; medication related to fertility treatment and trigger shots in connection with IUI cycles, if covered by your plan; ovulation predictor kits and pregnancy tests; and IVF insemination and related treatments, if covered by your plan, and for those aged 37 or younger, if you completed at least three IUI.

Fully completed and signed Out-of-Pocket Expense Submissions and accompanying support documentation must be received by the Settlement Administrator by Bar Date. Out-of-Pocket Expense Submissions will be evaluated by Special Master Hon. Steven Gold, who will determine what, if any, additional compensation you might receive from funds remaining in the Common Fund after all Participating Class Members have been paid their approximately $10,000 payment or proportionately reduced payment if there are more than 200 Class Members.

FUNDS FOR OUT-OF-POCKET SUBMISSIONS MAY NOT BE AVAILABLE. COMPLETING THIS FORM DOES NOT GUARANTEE ADDITIONAL COMPENSATION.

Identify the expense, what documentation you are providing in evidence of the expense, and how the expense is associated Aetna’s denial or anticipated denial of your infertility benefits.

Please retain copies of your documents for your own records. You will be notified by mail and/or email if anything additional is needed for your Out-of-Pocket Expense Submission. Please make sure the Settlement Administrator has your current mail and email addresses.