Hochgradige Schwerhörigkeit in der sozialgerichtlichen Rechtsprechung
Patients suffering from severe and profound deafness causing a medical indication for a hearing aid or a cochlear implant (CI) can have difficulties to get the consent of statutory health insurances or other insurance providers to cover the costs. Indication criteria for receiving a cochlear implant (CI) have widened over the last decades (single-sided deafness (SSD), electric acoustic stimulation (EAS), bilateral CI, CI in case of long-term deafness) and more and more patients come into consideration for such a treatment. Hence, disputes increasingly arise between patients and their statutory health insurance concerning the question whether surgery and follow-up treatment have to be paid for by the health insurance. Additional problems often arise concerning the question which further costs have to be covered by statutory insurances or other providers after the implantation, e.g. within the framework of integration aid. Also, when patients are provided with hearing aids, it is often unclear whether they are entitled to technically advanced and therefore more expensive hearing aids, or just to hearing aids for the reference cost. Goal of this work was to investigate how such disputes have been decided by the German social courts.
A search was executed for judgments in the two biggest commercial German legal databases and, in the cases concerning cochlear implants, in the database of the German social courts. The search parameters were “Cochlear”, “Cochlea”, “Implant”, and “Implantat” respectively “Hörgerät” (hearing aid) and “Zuzahlung” (additional payment). Three verdicts were attained by directly contacting the court, another one was gathered from an article. The reviewed judgments were issued between 2002 and 2019.
A total of 122 judgments were analysed. The court proceedings took between 2 months, and 10 years and 4 months. In cases concerning the question whether or not the costs for a cochlear implant have to be paid for, all patients except one won the lawsuit in the main proceedings. Of the patients claiming further costs after the CI implantation 54% won their case, of the patients fighting for more advanced hearing aids 63%.
The study shows that despite the amount of time the patient has to invest, taking legal action can be worthwhile in the majority of the cases, especially when it comes down to CI-surgery. Hence, it is recommended to take legal action, after thorough consideration, in cases where insurance providers refuse to meet expenses incurred.