MISCELLANEOUS HARM SUBMISSION

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MISCELLANEOUS HARM 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 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 June 1, 2024 and you were in an Eligible LGBTQ+ Relationship as described in the Settlement Notice, (2) you have not requested exclusion from the settlement, and (3) you experienced additional, miscellaneous harm arising from Defendant’s actual or anticipated denial of your coverage request(s) that are not covered by any of the other benefits provided by this settlement (including the out-of-pocket expense submission), you may be eligible for additional compensation and should complete this Miscellaneous Harm Submission.
Examples of Miscellaneous Harm include, but are not limited to, extenuating circumstances rendering fertility procedures traumatic; extreme delay or total loss of the ability to parent due to Aetna’s challenged policy; and medical complications or miscarriage associated with having to undergo fertility procedures you otherwise would not have undergone but for Aetna’s challenged policy.
Fully completed and signed Miscellaneous Harm Submissions must be received by the Settlement Administrator by Bar Date and 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 awarded their approximately $10,000 payment, or a proportionately reduced payment if there are more than 200 Class Members.
FUNDS FOR MISCELLANEOUS HARM SUBMISSIONS MAY NOT BE AVAILABLE COMPLETING THIS FORM DOES NOT GUARANTEE ADDITIONAL COMPENSATION
1. What harm did you experience as a result of Defendant’s denial or anticipated denial of infertility coverage that is not addressed by any of the other benefits offered by this settlement?
2. Provide details on how or why you believe the item(s) described in your answer to question 1 are the result of Defendant’s denial or anticipated denial of your request for infertility coverage.
3. Do you believe that the harm(s) you described is remedied? Why or why not?
4. Is there anything else you would like to share about what happened to you following the denial or anticipated denial of infertility coverage?
Upload any additional documentation related to your Miscellaneous Harm if Necessary.
Miscellaneous Harm Documentation
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Accepted file types: pdf, jpg, jpeg, bmp, png, Max. file size: 16 MB.
You will be notified by mail and/or email if anything additional is needed for your Miscellaneous Harm Submission. Please make sure the Settlement Administrator has your current mail and email addresses.
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- I certify under penalty of perjury that this Miscellaneous Harm Submission and any applicable documentation provided to substantiate my miscellaneous harm are true and correct to the best of my knowledge.
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Goidel et al., v Aetna Life Insurance Company