Two amputees recently sued the Anthem insurance company, claiming that the insurance company wrongfully denied their claims for prosthetic limbs. The company refuses to cover limbs that are not “medically necessary”. The requested limbs were microprocessor-controlled limbs, or limbs that are powered by sensors and an onboard computer.
The plaintiffs both requested that Anthem cover their microprocessor-controlled limbs, which Anthem refused to cover. According to its policies, Anthem does not cover services that are not “medically necessary”. The company has a list of criteria that a service must meet in order to be considered “medically necessary”. One of those criteria is that a service must be:
The most appropriate procedure, supply, equipment or service which can be safely provided. The most appropriate procedure, supply, equipment or service must satisfy the following requirements:
- There must be valid scientific evidence demonstrating that the expected health benefits from the procedure, supply, equipment or service are clinically significant and product a greater likelihood of benefit, without a disproportionately greater risk of harm or complications, for you with the particular medical condition being treated than other possible alternatives; and
- Generally accepted forms of treatment that are less invasive have been tried and found to be ineffective or otherwise unsuitable.
The company alleges that microprocessor-controlled prostheses are not medically necessary and denies the scientific evidence about the benefits of the devices. The plaintiffs are seeking compensation for their devices, as well as asking that the lawsuit be certified as a class action so that others who have been similarly affected can join.
If you are suffering from limb loss and your health insurance company has refused to pay for your prosthesis, call me, Conal Doyle, Los Angeles personal injury attorney, at 310-385-0567. I can help. Call today to learn more or to schedule a free consultation on your case.