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Since I began writing this column, I have received many letters from readers with disabilities or family members of the disabled citing what they perceive to be injustices toward them. Often, the case involves a company's refusal to pay for either an assistive-technology product or surgery that can correct a serious disability. Here's a story about one such case in Ohio. Frankly, this one baffles me.
The case involves cochlear implants for a three-year-old deaf girl in Ohio. A cochlear implant is an electronic prosthesis which, when surgically placed in the inner ear, partially performs the functions of the cochlear. That's the part of the inner ear that turns sound waves into coded electrochemical signals sent to the brain. The operation is expensive. It can cost as much as $50,000 -- and thousands more with the addition of post-operative speech therapy. But the results are phenomenal. Whole new worlds open up for deaf people who receive cochlear implants. They can take advantage of educational opportunities and join the workforce effortlessly.
Medicaid, Medicare, ChoiceCare/Humana, Aetna, and Anthem Blue Cross & Blue Shield are among the many health-care insurers who now cover cochlear implants. There's a strong economic argument for this. Researchers from Johns Hopkins University in Baltimore recently did a study that found that profoundly deaf children who receive a cochlear implant are more apt to be fully mainstreamed in school and to use fewer support services than similarly deaf children without an implant. The Johns Hopkins study estimated that for a three-year-old child who receives the operation, cochlear implants can save $30,000 to $50,000 in special-education costs for elementary and secondary school. Plus, a hearing child will have an easier time finding a skilled job than a deaf child -- and an employed person becomes at least a partial health-care payer.
KING CRISIS.
Yet some insurance companies still won't pay for cochlear implants, even though disability groups contend that the Americans with Disabilities Act compels them to provide coverage. Advocates argue that Title I of the ADA prohibits employers from providing insurance coverage that discriminates on the basis of a disability. And they contend that Title III prohibits insurance companies, as "public accommodations," from discriminating on the basis of a disability.
One company that won't pay for the cochlear implant operation is Benicorp Insurance Co., based in Indianapolis. For nearly a year, the company has declined $50,000 in reimbursement to Riley Children's Hospital in Indianapolis for the cost of a May 24, 1999, implant operation for then-three-year-old Erica King, the daughter of Mark and Angela King of Celine, Ohio. Mark King, the manager of a residential remodeling contracting company, has family health-insurance coverage through Benicorp at work.
Last December, the Insurance Dept. in Ohio ruled: "It is the position of this Department that the services recommended to Erica are eligible for payment under the certificate provided to Mr. and Mrs. King." Benicorp has also received letters from the U.S. Equal Employment Opportunity Commission, a well-known doctor who performs the implant operation, and several members of Congress, urging the company to pay the bill. At one point, the EEOC issued a subpoena because the company refused to respond to a separate discrimination complaint brought against it by the Kings. Benicorp fought the subpoena.
"NOT RIPE"?
In March, Erica's parents sued Benicorp to pay for the operation, plus $5,000 in post-operative rehabilitation costs. They contend that the ADA requires the company to pay. And they say that they may ask for more money if rehabilitative costs mount. The case, filed on Mar. 27, remains pending.
Benicorp's legal counsel, who asked not to be identified, issued this statement on behalf of the company: "The policy [in question] does not expressly cover cochlear implants. The policy covers only specific-listed prosthetic devices. Implants and transplants are not covered." Benicorp contends that determining policy coverage is a private matter that comes under the jurisdiction of the Employee Retirement Income Securities Act of 1974, not under the ADA, as the Kings contend.
In its response to the lawsuit filed in U.S. District Court, Benicorp has asked a judge to dismiss most of the case because the claim is "inappropriate under both Title I and Title III of the ADA." It argues that the ADA doesn't regulate the content of insurance policies. And the company says that parts of the case are "not ripe" for adjudication because the Kings haven't exhausted their administrative remedies.
LONG-TERM PAYOFF.
Mrs. King said before Erica had her cochlear transplant, the child was withdrawn and irritable. After the operation, "she came to life. She started smiling and talking. Nearly a year of speech therapy has made her a fuller and [more well-rounded] person." Erica's 18-month-old sister Jaime also has a hearing impairment and may require a cochlear implant. If she has the operation, will history repeat itself in the battle between the Kings and Benicorp? I hope it doesn't.
Almost 8,000 people in the U.S. have received cochlear implants, including several thousand children. Ninety percent of all health-care providers that work with Englewood (Colo.)-based Cochlear Corp. -- the world's largest manufacturers of such devices -- now cover the operation, says John McClanahan, head of reimbursements for the company. Is Benicorp so different from the other health-care insurance companies?
If Benicorp persists in fighting the case in the courts, it will have paid huge legal fees, perhaps exceeding the cost of the implant. Is this good business practice? Isn't it a better policy to expand the coverage to include the cochlear implant, an expensive but rare specialized operation?
Assistive technology is changing the world for disabled people, as it has for Erica King. Health-care providers should recognize this fact. A dollar invested in good health care today is sound long-term policy.
To comment on this and other assistive tech products and issues, visit BW Online's Assistive Tech Forum. Or drop John a line at JMMAW@aol.com EDITED BY DOUGLAS HARBRECHT
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