Blog

Last fall, two individuals who have suffered lower limb loss sued Blue Shield of California for failing to provide coverage for microprocessor-controlled lower limb prostheses. Blue Shield claims that the prostheses are “experimental or investigational in nature”, and therefore it is not required to provide coverage for them. Blue Shield, a health insurance company, has issued individual contracts about its coverage, each of which is called an “evidence of coverage” (“EOC”). All Blue Shield’s customers are provided with EOCs which set forth the terms and conditions of coverage. Within the EOCs is an exclusion for services or medical supplies that …

Recently, two individuals who have suffered lower limb loss sued Anthem, a health insurance provider, for its failure to pay for lower limb prostheses under the insurance plan. The plaintiffs are seeking to certify their lawsuit as a class action. In particular, the plaintiffs are suing Anthem because of its failure to provide microprocessor-controlled lower limb prostheses under the terms of the insurance plan. Anthem claims that it is not legally required to pay for those prostheses because under the terms of the policy, they are not medically necessary. Anthem uses four criteria that must be met in order to …

A lawsuit that was recently filed against Blue Shield of California, an insurance company, alleges that the insurance company wrongfully refuses to provide its customers with microprocessor-controlled foot prostheses. The lawsuit alleges that the company overlooks medical studies and other evidence in order to deny claims for the devices. Blue Shield has written and implemented written positions on coverage on various devices, including microprocessor prostheses. Blue Shield has a medical policy called “Microprocessor-Controlled Prostheses for the Lower Limb”. The medical policy for Blue Shield states that microprocessor-controlled lower limbs are considered investigational. However, the lawsuit alleges that studies have shown …

A lawsuit was filed last fall in federal court in California, alleging that Anthem, a health insurance provider, wrongfully denied claims for microprocessor controlled protheses for customers who had suffered lower limb loss. The lawsuit claims that the denials were in violation of federal employment benefit laws. Anthem has a coverage guideline called the Anthem Medical Policy on Microprocessor Controlled Lower Limb Prostheses, which the lawsuit alleges the company has used to deny most medical requests for the devices on the basis that they are not medically necessary. The company also claims that they are investigational devices, and therefore do …

At the end of 2017, two individuals who suffered limb loss sued United Healthcare in California, accusing the company of wrongfully denying claims for microprocessor prostheses. They are seeking to add additional plaintiffs and to certify the case as a class action lawsuit. The lawsuit claims that United Healthcare has developed and implemented a Coverage Determination Guideline called “Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs”. The Guideline provides that: “If more than one prosthetic device can meet the member’s functional needs, benefits are only available for the prosthetic device that meets the minimum specifications of the member’s needs.” The …

Two amputees sued Blue Shield of California over its coverage for prostheses. The plaintiffs allege that Blue Shield improperly failed to provide coverage for some prosthetic devices, as well as failed to maintain an adequate network of prosthetists. The lawsuit is seeking to become a class action lawsuit. The lawsuit alleges that there are so many individuals affected by Blue Shield’s actions that a class action is appropriate. The lawsuit also alleges that the claims are all similar, that all members of the class will have their interests protected by the plaintiffs, and that a class action is the correct …

According to a lawsuit recently filed against Blue Shield of California, the company wrongfully failed to provide coverage for microprocessor-control prosthetic feet. The lawsuit alleges that the company deemed them as “investigational” and refused to provide coverage. Microprocessor-controlled feet prostheses are artificial feet that respond to feedback from sensors to a computer in the feet. The computer can change resistance to downward motion and upward motion of a foot based on walking speed, incline, decline, and type of terrain. The computer can make adjustments in real time, which can decrease falls, increase stability, decrease discomfort and pain in the amputee, …

Two amputees recently filed a lawsuit against Blue Shield of California for failing to authorize payment for some types of prostheses and for underpaying out-of-network prosthetists for their services. The amputees are claiming that Blue Shield’s actions violated the Unfair Competition Law in California. They are seeking other amputees who have suffered financial losses as a result of Blue Shield’s practices to join the lawsuit. The plaintiffs claim that Blue Shield has a policy of claiming that microprocessor-controlled foot prostheses are investigational, and therefore will not cover them. The health insurance policies issued by Blue Shield do not provide coverage …

Two individuals suffering from lower limb loss have sued Anthem on behalf of themselves and others over Anthem’s policy to deny coverage for microprocessor controlled lower limb prostheses. The plaintiffs are asking the court to provide financial compensation to them for their losses, as well as to order Anthem to cover those limbs going forward. According to the lawsuit, Anthem has developed and used a coverage guideline called the Anthem Medical Policy on Microprocessor-Controlled Lower Limb Prostheses, Policy No. OR-PR.00003. Anthem uses that policy to deny claims for microprocessor controlled lower limb prostheses. Anthem claims that the microprocessor-controlled limbs are …

United Healthcare was sued late last year for failing to provide coverage for a prosthetic arm and hand for a 12-year-old boy named Logan. Logan does not have a right forearm and hand because of a congenital defect. He was insured under his mother’s health insurance plan with United Healthcare. As Logan has grown, he required new prosthetic devices to fit his body. He uses both hands to perform normal functions of a 12-year-old boy, such as typing, eating, and even playing his trumpet. A prosthetist recommended that he be fitted with an i-limb quantum device with a High-Fidelity socket/interface. …

According to a class action lawsuit filed late last year in California, Blue Shield of California (also known as California Physicians’ Service) has a practice of denying coverage for some lower limb devices. The company has also been accused of restricting payments for lower limb devices if the members seek services from an out-of-network provider. Under the lawsuit, the company is accused of denying coverage for microprocessor-controlled foot prostheses for all of its customers. The company claims that microprocessor-controlled foot prostheses are investigational. Most insurance companies deny coverage for investigational medical treatments or devices. The lawsuit also alleges that Blue …

A class action lawsuit was filed late last summer against Anthem, one of the largest health insurance companies in the U.S. Anthem was accused of denying coverage for some lower limb prostheses because they were determined to be “not medically necessary”.  The lawsuit is seeking damages for the amputees as well as an injunction against the company, as well as attorney’s fees. The lawsuit alleges that Anthem has developed a coverage guideline that it uses to deny claims for microprocessor controlled lower limb prostheses. According to the lawsuit, improvements in technology have allowed prostheses manufacturers to use microprocessors to power …