Health insurance must pay expensive hearing aid

Health insurance company has to pay for expensive hearing aid

16/10/2014

If someone can only compensate for his hearing loss with an expensive hearing aid, the health insurance company has to pay for these costs despite the fixed-amount regulation, according to a ruling by the Landessozialgericht Darmstadt (LSG). According to the press release of the LSG Darmstadt, an almost deaf administrative assistant had acquired a hearing aid for € 4,900 in a specific case after consulting a hearing care professional, as this almost completely eliminated his hearing loss and even enabled him to make a telephone call. His health insurance company did not want to approve the request for reimbursement of the difference and was only prepared to pay the fixed amount of 1200 €.

According to the press release of the LSG Darmstadt, the Sozialgericht rejected in the first instance the action of the man on the grounds that the latter had already acquired the hearing aid before the health insurance company declined and thus failed to comply with the prescribed procurement procedure.

Supply indicator includes comprehensive benefit application
The Landessozialgericht Darmstadt overturned this decision, however, and condemned the health insurance company to reimburse the approximately € 3,700. First, the judges found that the care indicator of the hearing aid auditor included a claim for the best possible care with a hearing aid. If the health insurance company grants it the fixed amount, it will thus inimit the assumption of costs for a higher-quality hearing aid supply. Since the health insurance company had been able to examine the application, the procurement procedure was also adhered to if the insured person bought the hearing aid before the health insurance company had expressly refused to cover the cost of the difference, the Provincial Social Court said.

Lack of evidence of a cheaper care option is at the expense of the health insurance
In addition, the judges pointed out that the health insurance companies - as well as the pension insurance - the hearing impaired insured persons do not have access to independent advice and assessment centers. Thus, the insured received no independent of profit expectations investigation and adaptation of eligible hearing aids. Rather, they would "outsource" this task to hearing healthcare professionals. Therefore, it is at the expense of the health insurance, if it can no longer be clarified in court, whether a cheaper hearing aid would have as far as possible to compensate for functional deficits, said the press portal of the LSG Darmstadt.
In addition, according to the LSG, the health insurance company can not rely on the hearing care professional being obligated to a non-contributory care. This contractual obligation relates only to the contractual relationship between the health insurance company and the service provider and has no effect on the aid entitlement of the insured person. The appeal was denied. (Jp)