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 are “Experimental or Investigational in Nature”. The phrase is uniformly defined as any treatments, devices, etc. which are not recognized in accordance with generally accepted professional medical standards as being safe and effective for use in the treatment of the injury or condition at issue.
Blue Shield has used that exclusion to deny claims for microprocessor-controlled foot prostheses. Two customers of Blue Shield have sued, claiming that microprocessor-controlled foot prostheses are not experimental or investigational in nature. The plaintiffs in the lawsuit claim that the prostheses are accepted in the medical field and are standard technology.
This lawsuit is adding additional plaintiffs who have had their claims for microprocessor-controlled foot prostheses denied by Blue Shield. If you are interested in learning more, call me, Conal Doyle, Amputation Attorney at 310-385-0567. I can discuss your legal options with you. Call today to learn more or to schedule a free consultation.