The Anthem insurance company has been sued by two individuals who have suffered from limb loss. The plaintiffs are claiming that the company failed to properly pay for their prosthetic limbs. The plaintiffs are seeking other individuals with similar claims against the company in order to certify the case as a class action lawsuit.
The lawsuit claims that the company denies requests for microprocessor-controlled knee prostheses based on erroneous criteria. The lawsuit claims that Anthem deems those prostheses as not medically necessary unless all four of the following criteria are met:
- The individual has adequate cardiovascular reserve and cognitive learning ability to master the higher level technology and to allow for faster than normal walking speed; and
- The individual has demonstrated the ability to ambulate faster than his or her baseline rate using a standard swing and stance lower extremity prosthesis; and
- The individual has a documented need for daily long distance ambulation at variable rates; and
- The individual has a demonstrated need for regular ambulation on uneven terrain or regular use of stairs.
According to the lawsuit, the four criteria are erroneous and unreasonable. The lawsuit claims that microprocessor-controlled knees are intended to help with activities of daily living, which are not taken into account in the company’s criteria.
If you have suffered from lower limb loss and your insurance company has refused to properly pay for a prosthesis, you should speak with an attorney. Call me, Conal Doyle, California amputation attorney at 310-385-0567. My team can help. Call today to learn more or to schedule a free consultation.