A 56-year-old woman came to Lifecare Innovations, Inc. (LCI) for assistance with a difficult insurance issue.  Her insurance company had recently denied her coverage for a much-needed cochlear implant surgery, basing their denial on the false impression that cochlear implants are hearing aids.

Cochlear implants are, in fact, not at all like hearing aids.  Hearing aids simply amplify sound for those who still have some auditory capability.  Conversely, cochlear implants actually replace the inner ear and stimulate nerves to produce sounds where none were transmitted before.  The ideal cochlear implant patient has had hearing capability in the past, and has had language development before hearing was lost.

Our client, the owner of a small farming company, had both hearing and language capability earlier in her life.  A progressive disease deteriorated the bones of her inner ear and caused her to become deaf.  She was thus a perfect candidate for a cochlear implant procedure.

As an insured individual outside of a group, however, our client had little or no leverage with her insurance company.  Her carrier repeatedly denied her coverage, in spite of her best efforts to educate them on cochlear implants, and they insisted on communicating with her via telephone when she most effectively communicated via fax and written documents.

LCI undertook insurance negotiations, which ultimately spanned a six-month period.  LCI filed a complaint with the Insurance Commission and documented 200 pages of correspondence between our client and her insurance carrier.  We negotiated with her insurance company’s chief counsel to settle the case without litigation.  The process was slow and painful; the insurance company was resistant to perceiving cochlear implants as anything other than amplification devices, and they conceded our client’s eligibility for surgery one step at a time.

The Outcome:

After several months of persistent advocacy for our client, LCI succeeded in obtaining insurance coverage for our client’s cochlear implant surgery.  In the end, in fact, the client’s insurance company teamed with LCI to negotiate the cost of the procedure down to a very manageable level.  The following results were achieved:

  • The hospital, surgeon and anesthesiologist all provided their services at a 20 percent discount for our client;
  • The actual cochlear implant devices were purchased at cost from the manufacturer, enabling us to avoid a $16,000 surcharge traditionally levied by the hospital when they procure the implants;
  • Initial costs for the procedure and implants were $55,000.  Our negotiations led to a 50 percent decrease in the overall price of the surgery and devices.
  • Our client’s insurance carrier covered all expenses.  The client paid only our fees.