Two people suffering from limb loss sued the Anthem health insurance company for its failure to pay for their artificial limbs. The company labeled the limbs as “investigational” and was sued as a result.
According to Anthem’s internal guidelines, the company will not cover any “investigational” services. The company uses seven criteria to determine if a service is investigational: 1. It has limited use on humans, which is not generally accepted as proven and effective procedures within the organized medical community; 2. It does not have final approval from the appropriate governmental regulatory body; 3. It is not supported by scientific evidence which permits conclusions concerning the effect of the service, drugs, or device on health outcomes; 4. It does not improve the health outcome of the patient treated; 5. It is not as beneficial as any established alternative; 6. The results outside the investigational setting cannot be demonstrated or duplicated; or 7. It is not generally approved or used by doctors in the medical community.
The plaintiffs claim that the criteria are erroneous when applied to some prosthetic devices. The documentation from the company cites studies to prove that the limbs are investigational, when the studies actually conclude that the devices provide significant benefits over other limbs.
The plaintiffs are asking the court to force the company to change its policies, as well as to compensate them for the limbs that were denied. If you have had a claim for a prosthesis denied by an insurance company, you should speak with an attorney. I can help. Call me, Conal Doyle, personal injury attorney at 310-385-0567. My team can help. Call today to learn more or to schedule a free consultation.