Late last year, two individuals suffering from limb loss who were customers of Blue Shield sued the company over its failure to pay for certain types of prosthetic limbs. The customers claim that the company acted in bad faith in refusing to pay their claims. They are seeking to turn the lawsuit into a class action and to force the insurance company to reimburse them, as well as to pay for the limbs going forward.
The limbs that the company has refused to provide are microprocessor-controlled limbs. They are limbs that are operated by a computer. They can change the resistance of the limb based on feedback from sensors in the limb. They can help decrease falls, increase stability, and decrease the discomfort and pain associated with a prosthetic limb. They are more expensive than body-powered limbs, but have been in use for decades and are regularly prescribed for patients.
Blue Shield has implemented written coverage positions on various services that are requested by members. The written positions are called “Medical Policies”. Blue Shield has developed a medical policy called “Microprocessor-Controlled Prostheses for the Lower Limb”, which sets forth the company’s coverage position on microprocessor-controlled feet. It says that microprocessor-controlled feet are investigational, and therefore not covered.
The plaintiffs allege that there is more than sufficient evidence of the effectiveness of the devices, and that Blue Shield is wrong to label them as investigational. They are seeking to certify their case as a class action. If you have had your claim for a prosthetic limb denied by Blue Shield or another insurance company, call me, Conal Doyle, personal injury attorney, at 310-385-0567. I can help. Call today to learn more or to schedule a free consultation.