ANA Discussion Forum
General Category => Insurance => Topic started by: Tamara on October 27, 2008, 07:23:03 am
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I was musing on Soundy's insurance dilemma and was struck by some thoughts about coverage for the BAHA (or transear, for that matter). First, the term "hearing aid" implies that there is some hearing on that side left to aid. There is not so it should not be considered an aid. Think of the following comparisons:
A cane or walker could be considered a "walking aid", but a prosthetic leg would be covered by insurance.
Eyeglasses or contacts could be considered a "seeing aid" but a corneal implant would also be covered.
Why is the sense of hearing discriminated against?
Maybe someone can use these ideas in an appeal letter, or to explain the difference to dense insurance people.
Best wishes,
Tammy
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Tammy:
The insurance company people are not really dense, but quite clever. Its just semantics. The fine print in your insurance policy very likely defines what is meant by a 'hearing aid'. Since SSD folks like us do have 50% of our 'natural' hearing, the BAHA can probably be defined as an 'aid' to the hearing ability we have. Its a word game the insurance companies play in their contracts, written by lawyers, to give them legal justifications for denying coverage. Fortunately, not all companies define a BAHA the same way and policyholders still have the option of appealing and even going to court, should it ever be necessary (and deemed to be worth the time and expense). I 'm rooting for Soundy to win her BAHA fight with logic and perseverance. :)
Jim
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So, by that logic, one would have 50% of their "natural" walking ability with one leg, and 50% of their "natural" seeing ability with one eye?? ;) Hmmm. I do realize that sometimes the insurance companies are in the business of not paying claims, and of course the wording helps them. I have written a number of appeal letters over the years to various companies (not related to my AN or BAHA) and have used examples like this occasionally to make my case - Usually successful.
Also rooting for Soundy!
Tam
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Tammy,
I was just wondering, did your insurance cover the cost of your BAHA? I'm almost certain that I've read most insurance does, but occasionally, one like Soundy's doesn't.
Thanks,
Wendy
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So, by that logic, one would have 50% of their "natural" walking ability with one leg, and 50% of their "natural" seeing ability with one eye?? ;) Hmmm. I do realize that sometimes the insurance companies are in the business of not paying claims, and of course the wording helps them. I have written a number of appeal letters over the years to various companies (not related to my AN or BAHA) and have used examples like this occasionally to make my case - Usually successful.
Also rooting for Soundy!
Tam
Tammy:
That's correct. You don't 'medically' require a hearing aid if you have 50% of your 'natural' hearing. It's considered a choice, not a need. By that standard, a person with one leg doesn't 'medically' require a prosthetic leg to function. Insurance companies do try to avoid paying claims and write their policy language to help them justify not paying claims. They also fund politicians that will introduce laws that favor insurance companies position in regard to claims. Perseverance, using logic and understanding your policy language, limitations and exclusions as well as state law regarding insurance companies all help facilitate getting a claim approved and paid. My wife, a former insurance claims supervisor, used to tell recalcitrant claim representatives she dealt with while disputing a claim (not with her former employer's company) that she had the state insurance commissioners number on her speed dial. That comment and her understanding the state law and the policy language all helped her win her claim without going to court or having to engage in a long, tedious appeals process. Putting your case in writing is always a good idea. I hope you'll continue to be successful, right along with Soundy. :)
Jim
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What happens if you have 49% of your hearing? It seems to me that many people have lost a little bit in both ears, if you are comparing to the audiologist definition of perfect hearing. So if you are SSD on one side, and down a tad on the other, aren't you below the magic 50% number?
Just looking for an angle...
Steve
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I am in an insurance fight of my own over a BAHA. Part of the issue, I believe, is that the BAHA--bone anchored HEARING AID had the word hearing aid in its definition. We all know it is not a real hearing aid, as I have no hearing to aid. As I've explained to my insurance company, I am deaf, not heard of hearing. My biggest complaint is that a cochlear implant would be covered. I am taking the angle of them being discriminatory regarding my hearing loss. I also wish the BAHA would change their name because insurance companies, who have no idea what a BAHA is, think that if the device has the name 'hearing aid' in it, they must know what they are talking about. Of course then, a bone anchored hearing implant or BAHI wouldn't sound as nice.
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I kind of like BAHI (BA - HEE)...
K
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I have hearing loss in hearing ear and so am below 50%... still have a battle ... what is killing me is this
high deductible plan they changed to to save a little ... I would much rather pay the little over $100 more
a month that we were paying and have better coverage... if we had the money I would get a private
policy not associated with my husbands work place and be done with them ... but have checked and
the $500+ per month for just me is out of reach...
The language is something you have got to watch and be weary of ...one sentence that pops up
through out our policy is regarding payment ... it will say they pay "80% of covered charges" but
doesn't list what those covered charges are ... some have gone in and had procedures done and a
week or two later get a big bill and can't figure why until they look through what charges are not covered...
they go in thinking that if the doctor ordered it that it is covered... if it said "80% of charges" everything
would be covered at 80% ...one little word suddenly becomes huge...
Going to use some of this wording in a letter if my next appointment doesn't go well... my main concern is still
the increase in head pain ... they turned down a new scan as unnecessary unless an emergency and it was
suggested that next time it starts getting bad to not take anything until I am to the point of vomiting
and unable to function safely on my own then have someone to take me to ER... this is not acceptable
to me ... and should not be the option that will get something started to find out what has changed to
have an increase in pain
They may think they can drive me nuts and make me go away , but I am stubborn as they come and won't
quit...I may not get anywhere , but not going to quit trying either
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oHIo -
it is my understanding from talking to my insurance broker that if an insurance company covers Cochlear implants, they HAVE TO cover BAHAs. The only reason you don't need a Cochlear is because you are not bilaterally deaf - you are unilaterally deaf. That is basically the one essential difference between the Cochlear and the BAHA.
If your insurance company does not consider the Cochlear to be a hearing aid, they can't logically consider the BAHA to be one either. And even though insurance companies aren't always logical, they will be hard pressed to defend their position on covering one but not the other.
If you haven't already pointed that out to them, you should. If they still refuse coverage, mention the words "lawyer" and "discrimination" - it usually gets their attention ;)
Good luck,
Jan
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oHIo -
it is my understanding from talking to my insurance broker that if an insurance company covers Cochlear implants, they HAVE TO cover BAHAs. The only reason you don't need a Cochlear is because you are not bilaterally deaf - you are unilaterally deaf. That is basically the one essential difference between the Cochlear and the BAHA.
If your insurance company does not consider the Cochlear to be a hearing aid, they can't logically consider the BAHA to be one either. And even though insurance companies aren't always logical, they will be hard pressed to defend their position on covering one but not the other.
If you haven't already pointed that out to them, you should. If they still refuse coverage, mention the words "lawyer" and "discrimination" - it usually gets their attention ;)
Good luck,
Jan
Good points, all, Jan.
I would just add that when mentioning the words 'lawyer' and 'discrimination', do so as calmly as possible. Insurance company claim reps are used to irate people threatening to sue and are not always impressed, just annoyed. One insurance rep told a friend who used the 'L-word' "we have lots of attorneys on retainer", demonstrating a distinct arrogance that is all too common with an industry that routinely is sued by angry litigants who lose as often as they win. You only read about the big-buck verdicts against insurance companies. The 'little' lawsuits are often settled out of court (for a pittance) or denied a hearing by a judge that finds the case to be devoid of merit. I still like the veiled threat that the words 'insurance commissioner' infer. I think this has as much if not more weight with insurance company phone reps than 'lawyer', although 'discrimination' seems to convey a note of gravitas that might actually persuade an insurance company phone rep to consider listening to a claimants argument. Too bad we have to play these silly games but they often pay off . Frankly, I would rather argue my case with an insurance company that is in business and tightly regulated than some vast government bureaucracy with bored 'civil servants' on the other end who are basically unaccountable and work within a monolithic system that cannot be effectively challenged because it is run by the government. But, that's just me.
Jim
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I am trying to word my appeal very carefully. I have a statement (that I am working on still) that says something to the effect of it appears discriminatory that a cochlear implant is covered, yet a BAHA isn't when both are considered hearing implants/prosthetic devices, not hearing aids.
Jim, you are correct that they have attorneys on staff and don't care a bit to muscle the consumer if they have to. I believe they have already consulted legal in my case, because the reason they denied the BAHA has changed several times. I was to have a peer to peer review with my doc and theirs, and their doc did not show. They said he was "very thorough" which in my head means he was consulting legal to figure out how to handle this and what angle to take.
They finally emailed me links to part of their site regarding cochlear implants and BAHAs. I had to go under provider information (like I could have found it on my own ::)) and do some searching...quite a bit even with the links provided. It seems my dear old insurance company is not up to date on BAHA info (like I am surprised about that) deems it experimental and lists another maker of the BAHA, not Cochlear America. It appears the initial policy was written in 1974 (when I was in jr. high school) and has been updated as recently as 8/08. I was told they could not send me anything in writing as the policy guidelines/criteria are "constantly changing" Now that's reassuring. :o
Like Soundy, I will keep fighting. And Soundy we all know insurance companies will never commit to what they will pay, and how much. Some doctors will write off anything over usual and customary. Hospitals usually don't.
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Another thing to keep in mind is that insurance companies usually have a group mentality. If you can show them that it is "usual and customary" for most insurance companies to cover this, they may acquiesce. We know that Medicare covers it, and that's a big one. I have United Health Care. What other insurances have covered this, group?
Tam
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Tammy has an excellent point. Medicare does cover BAHAs and if they were "experimental" I don't think that would be happening.
It sounds like your insurance company just isn't up to speed on BAHAs, oHIo, and I'm not surprised. I was kind of shocked that lots of my doctors (not my neurotologist) had no idea what a BAHA is. My ENT had never heard of one :o
As far as the litigation thought goes, I wasn't offering it as an idle threat to your insurance company. I was offering it as a serious possibility. Yes, insurance companies can be big bullies and have lots of legal counsel, but the law is the law. BAHAs are technically Cochlears. If they cover one, I'm 99.9% sure they have to cover the other.
Jan
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oHio,
Just as a point of interest, BAHA was invented by a Swedish company called Entific and that company has since been acquired by Cochlear -- I'm not sure when, but I thought this information might somehow be helpful. I hadn't read this entrire thread before and everyone makes very good points. I called my insurance company again today and although I was able to determine that they cover the implant surgery I couldn't get an answer regarding the processor. The rep I spoke to said that answer will come during precertification but assumes it will. We all know the old adage about assuming though, so I assume nothing.
Tammy - Very good point about insurance companies having a group mentality and Medicare. If I have to fight the insurance company, these are good arguements.
Jan - A very interesting point you make about insurance coverage and Cochlear implants
Wendy
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Another point I forgot to mention in my last post.
Often insurance companies send claims and precertifications "out for review". When they do this, make sure your claim or precertification is reviewed by a doctor who has qualifications comparable to your doc. This is a called a "peer review" and it is YOUR RIGHT as an insured.
For example, if your BAHA surgery is to be preformed by a neurotologist, insist that the insurance company have their review done by a neurotologist who does BAHA implants. If they have a regular MD or an ENT review your request, chances are you'll be turned down because the regular MD or ENT is unfamiliar with BAHAs.
After my AN surgery my insurance company questioned why my hospital stay was 6 days when they felt it should be only 5. I asked how they determined that. They told me that the review their doctor had done said that 5 days was the standard. I asked what their doctor's qualifications were. I was told he was an internist. While I have nothing against internists, I told them that an internist who was unfamiliar with my case and has never performed brain surgery had no business telling me, or my very qualified doctor who has performed many brain surgeries, how long I should be hospitalized after my surgery. I insisted that they do a peer review. The 6th day was paid for in full, which is a darn good thing because I couldn't have afforded it.
Bottomline, the more money insurance companies pay out in claims, the less they can keep in their pockets. Sometimes you've got to fight them to get what you're entitled to.
Jan
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Hi Jan,
You make some very good points. Glad you know how to stick up for yourself too, I've learned not be be afraid of pushing for what I believe I'm entitled to with insurance companies. When my mother had leukenia and was dying my parents insurance companyt decided to start giving them a hard time and even dropped her. I went to the New York State Department of Insurance with thier case and even though it took months, all the bills were paid retroactively to the date that the insurance was discontinued. I'm sure the insurance company probably got a slap in the wrist too. My father never had a problem with that company again.
Wendy
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Wendy -
that brings up another good point. Every state has a department of insurance that insureds are entitled to appeal to. I may be wrong, but I believe your insurance company is required to tell you this.
If you think your coverage request has been denied unfairly, or your claim has been handled incorrectly, you can contact your department of insurance without penalty from your insurance company.
Might be an option for Soundy, but I'm not certain.
Jan
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The woman at work that does insurance fights has talk to people on the state level and that is
an option that will be pursued if things don't start going alot better ... she is having to fight for
her husbands right to treatment which is good for the rest of us that are having problems ...
According to the state they can not find anything illegal that BCBS is doing ...
the high deductible plans lie we were switched to , are to reduce unnecessary trips to doctors and
unnecessary hospitalizations ... we had a man that had a supplemental AFLAC plan that paid directly
to him and would take his child to the ER for something as simple as a splinter... the old plan
paid the ER bill and AFLAC sent him money... abuse like this is what is costing me now in health
care I am not getting ...
I did find out that Tenn Care would pick me up under a catastrophic plan ... but I have to divorce
my husband and collect no alimony and live in a different residence and not earn any more
than $469 a month... sounds like a plan to me (read with sarcasm)