Late last year, two customers of Blue Shield, a health insurance company, sued the company for its policies on prosthetic limbs. Among the causes of action listed in the lawsuit is the allegation that the company failed to keep enough in-network prosthetists, who are individuals who make prosthetic limbs. According to the lawsuit, this has forced some customers of Blue Shield to pay out-of-pocket for their limbs.
Blue Shield has entered into contracts with its customers. Each contract is called an evidence of coverage (“EOC”). One of the company’s EOCs provides that:
The Blue Shield health plan is designed for Members to obtain services from Blue Shield Participating Providers and MHSA Participating Providers. However, Members may choose to seek services from Non-Participating Providers for most services. Covered Services obtained from Non-Participating Providers will usually result in a higher share of cost for the Member. Some services are not covered unless rendered by a Participating Provider or MHSA Participating Provider.
The lawsuit alleges that implicit in the EOCs is the promise that Blue Shield will have a fully formed network of providers so that its customers can receive the primary benefit of the contract, which will protect the customer from large out-of-pocket expenses. However, according to the lawsuit, Blue Shield does not have an adequate network of prosthetists because its reimbursement rates are so low.
The lawsuit is seeking compensation for those individuals who have been forced to pay out of pocket for their prosthetic limbs. If you are a customer of Blue Shield and you believe the company wrongfully denied your claim for a prosthesis, call Conal Doyle, Amputation Attorney, at 310-385-0567. He is currently working on several class action lawsuits against insurance companies and can help. Call to learn more or to schedule a free consultation.