CLAIM ASSISTANCE ON A DEPENDENT CHILD

An employee phoned our Service Team regarding coverage for hearing loss under her employer's group medical contract. Her infant son had recently been diagnosed with severe to profound cochlear hearing loss; the pediatric specialist recommended hearing aids. Prior to receiving the needed hearing aids, the employee, plan administrator and our service representative phoned the insurance carrier to obtain specific benefit coverage offered under the plan. We were informed, prior to receipt of services, that hearing impairments were a covered expense due to a Texas State Mandate.

We were quite surprised when the employee faxed a copy of the Explanation of Benefits received by from the carrier denying coverage. Our service department immediately began researching the unexpected denial. Through numerous conversations with claims analysts and supervisors, we were able to convince the carrier that we had originally received a confirmation of coverage for the hearing aids. Based on our notes, the carrier agreed to research their phone logs and identify the recorded conversation. The recording confirmed our notes. The claim examiner had misquoted the coverage. We asked the carrier to pay the claim based on the original confirmation of coverage even though incorrect. The carrier agreed and we resolved the situation to the client's satisfaction.