I am an amputee and am having trouble getting my insurance company to pay for a socket replacement or for a new prosthesis. What should I do?

Dealing with insurance companies as an amputee can be incredibly frustrating. There is often a maze of red tape that must be waded through in order to get the medical services to which you are entitled under the terms of the policy.

In many cases, the new prosthesis or adjustment to a prosthesis is denied because of documentation requirements that are not fulfilled. Insurance companies must see documentation showing the services that you require. Insurance companies look at the treating physician’s records, not the prosthetist’s records. The doctor who writes the prescription must be able to show why a prosthesis is needed.

Unfortunately, since doctors are not prosthetists, they do not always understand why a certain socket could be beneficial to an amputee. Prosthetists, as well as patients, must tell the doctor what is needed and why. If there is a problem with your socket, you should tell specifically the problems it is giving you – is it causing health problems, limiting your activities, causing pain in your residual limb, or is the socket damaged or worn out? You should also tell your doctor what the solution is, and why your prosthetist feels that would be the best course of action. Your doctor should document your conversation and submit the records to the insurance company.

Socket adjustments and repairs, as well as new prostheses can be covered under the insurance policy, if it can be shown there is a medical necessity. Normally repairs and adjustments are covered under the original order for the prosthesis, but if the socket must be repaired, or another expensive change is made, there must be a new prescription and documentation.

The bottom line is the best way to get insurance to cover your socket replacement, or a new prosthesis, is to work with your doctor and your prosthetist to submit a solid claim. If your insurance company refuses to pay, it may be time to speak with an attorney. Call me, Conal Doyle, Amputation Attorney, at 310-385-0567. I am an amputee as well as a personal injury attorney, and I help amputees fight insurance companies that are acting in bad faith. Call today to learn more or to schedule a free consultation.