ORANGE COUNTY, Fla. — A local 3-year-old was told her hearing aids weren’t covered by insurance, and another local kindergartener was told his crutches weren’t covered either, even though his Spina Bifida limited his ability to walk.
9 Investigates reporter Karla Ray that found families of kids with special needs are routinely denied medical equipment by their insurance companies. However, some of those claims are eventually pushed through if you fight back.
Many 3-year-olds would find it hard to sit for hours of speech therapy every week, but it’s the only way Brianna Giddens’ parents believe she’ll be able to speak.
“It's just frustrating. This is the most critical point of language development for a child,” Megan Giddens, of Oviedo, said.
Some of the therapy Brianna needs is paid for by insurance. But what’s even more crucial to counter her hearing loss, caused by a virus called CMV, are hearing aids. Those are not covered by insurance company AvMed.
The Giddens said a representative told them they were considered “cosmetic,” but AvMed told 9 Investigates in a statement that they would never deny coverage for this reason. Instead, the company would refer the customer to a partner service for discounted equipment, and offer the alternative of a cochlear implant. 9 Investigates found that most companies, including AvMed, do not cover hearing aids, but they do cover cochlear implant surgery.
“To me, that’s a shame. We’re talking about our 3-year-old daughter who has hearing loss, it’s not covered,” Jason Giddens said.
The Giddens are not alone. Chance Kern was born with Spina Bifida and has limited use of his legs. He was denied the use of a walker, and crutches, by a different insurance company.
In that case, Cigna approved the equipment on appeal.
“To me, it seems like they’re going through blindfolded, approving and denying things,” Amanda Kern said.
Kern points out that her son has light-up wheels on his wheelchair, which were approved without question by the same insurance company.
“I don't understand why they would approve that, but they wouldn't approve medical equipment that would help him be able to get stronger and walk,” Kern said.
“The reasons for denial are not based in fact, or the language of the policy,” attorney Matt Morgan said.
Consumer protection attorneys fight hundreds of thousands of denied claims in court each year. However, Analysis from the Government Accountability Office showed that about half of claims denied by private insurance companies are eventually overturned.
“When a big powerful insurance company tells you you're not entitled based on this complicated language, the consumer says, 'Well I guess I'm out of luck,'” Morgan said.
The Giddens said surgery for a cochlear implant would be considered under their plan, even though hearing aids are not.
“An invasive surgery would be covered, but something external, to have access to sound, isn’t,” Giddens said.
For now, the Giddens are saving up, knowing they’ll have to replace Brianna’s hearing aids in the next few years at a cost of around $5,000 for the entire system.
AvMed pointed out that the hearing aids wouldn’t be considered a denial, but rather a policy exclusion.
Cigna representatives also told 9 Investigates that the appeals process is thorough, fair and provides an important consumer protection, and the company encourages its customers to use the process if they disagree with a coverage decision.
If you need help fighting a claim, there are advocacy groups dedicated to helping.
Cox Media Group
