For more stories like this, sign up for the PLANSPONSOR NEWSDash daily newsletter.
Compliance October 15, 2004
Denial of Ear Implant Coverage Rejected
October 15, 2004 (PLANSPONSOR.com) - A Kansas woman
trying to get health coverage for an ear implant won a
sweeping legal victory when a federal judge ordered her
husband's company to pay the claim after ridiculing the
reasons they had first refused to do so.
Reported by Fred Schneyer
>US District Judge Kathryn Vratil of the US District Court for the District of Kansas overturned the decision to deny coverage to plaintiff Carolyn Baker for a cochlear implant when she lost her hearing, saying it was “arbitrary and capricious.” Not only that, Vratil ruled, the coverage denial notices Baker received from the Tompkins Industries health plan didn’t meet the requirements of the Employee Retirement Income Security Act (ERISA) by being vague and by not giving Baker enough information to properly appeal the decision.
Vratil rejected Tompkins’s argument that the cochlear implant was not medically necessary because it was not “for the purpose of restoring health and extending life,” as required by the plan’s summary plan description. “With their emphasis on ‘extending life,’ defendants would apparently limit plan coverage to life-threatening conditions and treatments which are specifically designed to increase length of life. Such an interpretation is patently unreasonable, however, in light of other plan provisions,” Vratil wrote in her ruling.
In addition, the court rejected Tomkins’s contention that the plan expressly excluded cochlear implants because the implants were designed to replace human organs: “Defendants do not explain how a cochlear implant replaces a human organ. The cochlea is one part of an ear, and the body implant exclusion excludes devices that replace human organs.”
In March 2000, Baker was treated for strep, pneumonia, meningitis and encephalitis and lost all hearing in both ears. Doctors recommended a cochlear implant in her left ear for which Baker requested coverage. The claim was denied first in September 2000 by Tompkins – Baker’s husband’s company – and twice more after administrative appeals. The final denial letter included a ruling that the implant was not medically necessary.
Baker then sued Tomkins in federal court, contending that Tomkins violated ERISA by sending her insufficient benefit denial letters and by ultimately denying her claim for benefits.
The case is Baker v. Tomkins Industries Inc., D. Kan., No. 03-2434-KHV, 10/7/04. The opinion is at http://www.ksd.uscourts.gov/opinions/032434KHV-50.pdf .