Category: Amputation

Late last year, amputees sued three insurance companies for their failure to provide computerized prostheses to their customers. The plaintiffs in the cases are seeking to turn the lawsuits into class actions.

The insurance companies that were sued are Anthem, United Healthcare, and Blue Shield. The lawsuits were filed in California. Each lawsuit was filed by two individuals suffering from limb loss, whose claims for microprocessor-controlled prostheses were denied. The lawsuits allege that the companies offered various justifications for why the prostheses are not necessary, such as claiming that they are “investigational”, “not medically necessary”, or that other, less expensive prostheses will meet all of the amputee’s needs.

The lawsuits claim that microprocessor-controlled prostheses have been in use for decades and are not experimental or investigational, but instead are regularly prescribed to amputees. The lawsuit also claims that although insurance companies claim that a less-expensive, body powered prosthesis will meet the amputee’s needs, microprocessor-controlled prostheses offer significant benefits to amputees when compared with basic body-powered limbs.

If you are suffering from limb loss, and your insurance company has denied your claim for a prosthesis, call me, Conal Doyle, Los Angeles personal injury attorney, at 310-385-0567. I am working on the lawsuits against insurance companies and will be happy to help. Call today to learn more or to schedule a free consultation.

Two individuals suffering from limb loss have sued the Anthem Insurance Company for its failure to provide prostheses for its customers. Among other allegations contained in the lawsuit is the claim that the company denied claims for all microprocessor-controlled foot ankle prostheses. The company has labeled them as investigational and not medically necessary for all indications.

The lawsuit claims that microprocessor-controlled foot-ankle devices use technology to simulate the movements of a normal foot and ankle. The device responds to constant feedback from sensors to the microprocessor, which changes the downward and upward motion of the foot based on walking speed, incline, decline, and type of terrain. The device then makes adjustments in real time. According to the lawsuit, this type of device helps create stability, decreases stumbles and falls, improves ambulation, and decreases the comfort and pain associated with a prosthesis.

The lawsuit alleges that Anthem has wrongly denied coverage for all requests for microprocessor-controlled foot-ankle prostheses. The company had a written policy that stated that microprocessor-controlled foot ankle prostheses are always considered investigational and not medically necessary. The plaintiffs sued the company, alleging that the devices are commonplace and are not investigational.

The lawsuit against Anthem is seeking to become a class action lawsuit. If you are an amputee and you have had your claim for a prosthesis denied by an insurance company, you should speak with an attorney. Call me, Conal Doyle, California amputation attorney, at 310-385-0567. You may be eligible to join one of the ongoing lawsuits. Call today to learn more or to schedule a free consultation.

A lawsuit is currently underway against United Healthcare for its failure to pay for prosthetic limbs for some of its customers. One of the customers who is currently involved in the lawsuit is a 12-year-old-boy suffering from limb loss. The plaintiffs are seeking to turn the lawsuit into a class action.

The boy was covered under his mother’s insurance plan issued by United Healthcare. He suffers from a congenitally-acquired absence of the right forearm. As he has grown, he has required new prosthetic devices to fit his body. His prosthetic forearm and hand help him to perform everyday functions such as eating, typing, hygiene, playing the trumpet, and other tasks.

A prosthetist recommended an i-limb quantum device with a High-Fidelity socket/interface. This device is powered by microprocessors. It has articulating fingers that simulate a human hand by providing the six fundamental grips of the human hand. It lets users use a keyboard, cut food, and perform many other tasks of daily living that cannot be performed with a body powered device.

United Healthcare denied the request for the device, stating the it exceeded the minimum specifications for the boy’s needs. His mother appealed, and the appeal was denied. The prosthetists put together a new detailed order for a less expensive prosthesis, which United again denied. The boy’s mother sued, alleging that the company failed to provide any reasons or facts supporting the denials, but instead issued a blanket statement that the device was not covered.

If you have had a claim for a prosthetic device denied by an insurance company, call me, Conal Doyle, Los Angeles amputation attorney, at 310-385-0567. I can help. Call today to learn more or to schedule a free consultation on your case.

Some customers of Anthem, a health insurance company, have sued the company in California, claiming that its policies wrongfully deny prosthetic limbs to some amputee customers. The amputees allege that the company has wrongfully labeled some limbs as “investigational” in spite of studies that show otherwise.

The lawsuit alleges that the company has refused to pay for microprocessor-controlled prosthetic limbs. Those limbs are controlled by computer chips instead of the human body and can result in significant benefits to users. They are much more expensive than limbs that are controlled by the body, and as a result many insurance companies are refusing to pay for them.

According to the lawsuit, Anthem’s written policies acknowledge that there are studies that demonstrate the benefits offered by microprocessor-controlled prostheses. The policies even reference studies that conclude that microprocessor-controlled prostheses provide significant benefits over other prostheses, yet the company concludes that the technology is “experimental and/or investigational”.

The lawsuit is asking that Anthem be required to provide microprocessor-controlled prosthetic limbs to its customers and is seeking to be certified as a class action lawsuit. If you or a loved one has had a claim for an artificial limb denied by Anthem, call me, Conal Doyle, California personal injury attorney, at 310-385-0567. I am working on several lawsuits against insurance companies for their failure to provide prosthetic limbs and I can help. Call today to learn more or to schedule a free consultation on your case.

A lawsuit that was filed last year by customers of Blue Shield who are suffering from limb loss made several allegations against the company, claiming that it is violating the terms of its contracts with customers in several ways. One of the allegations contained in the lawsuit is that the company wrongfully has a very small network of prosthetists, which results in individuals who need artificial limbs often being forced to pay a large percentage of the cost out of their own pockets.

According to the lawsuit, Blue Shield’s contract with its customers has language about in-network providers. The contract states 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 language in the Blue Shield policies is the promise that Blue Shield will develop a fully formed network of providers which will allow a member to receive the primary benefit of the contract, which is to give members the right to receive services from an in-network provider. However, according to the lawsuit, Blue Shield has been unable to maintain an adequate network of prosthetists because of its very low reimbursement rates to them. Therefore, according to the lawsuit, members who have suffered from limb loss are often forced to use out-of-network prosthetists, which leaves the members with a large out-of-pocket expense.

If you have insurance with Blue Shield and you have been left with a large bill for an artificial limb, call me, Conal Doyle, Amputation Attorney, at 310-385-0567. I am currently working on several lawsuits against insurance companies on behalf of amputees, including the lawsuit against Blue Shield. Call today to learn more or to schedule a free consultation.

Two individuals who are suffering from limb loss sued United Healthcare in California, claiming that the company wrongfully denied their claims for prosthetic limbs without properly investigating their situation. They are asking the court to certify the lawsuit as a class action so that other individuals whose claims for prostheses have been wrongfully denied by United can join in on the lawsuit.

United Healthcare has written guidelines that it uses to implement its insurance policies. One of those guidelines is called “Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs”. That guideline states 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 lawsuit alleges that United Healthcare has used its written policy to systematically deny claims for prosthetic arm and leg devices without assessing the individual’s functional needs, without assessing if the requested device meets the minimum specifications of the individual’s needs, and without identifying an alternative device that does meet the minimum specifications of the individual’s needs. Instead, the lawsuit alleges that the company simply issues a denial when certain prosthetic devices are requested.

If you are suffering from limb loss and you are covered by an insurance policy, and the insurance company has refused to pay for a prosthetic limb that you requested, call me, Conal Doyle, Amputation Attorney, at 310-385-0567. I am currently working on several lawsuits against insurance companies and I can help. Call today to learn more or to schedule a free consultation.

Currently, there are lawsuits underway against Blue Shield, Anthem, and United Healthcare for their failure to provide certain types of prosthetic limbs to their members. The lawsuits are seeking damages and may be certified as class actions.

The lawsuits were all filed late last year. All allege that the insurance companies involved refused to pay for microprocessor-controlled prosthetic limbs. Microprocessor-controlled limbs use computers to control the limbs, using feedback from the limb. The other type of common prosthetic limbs is body-powered limbs, which have been shown to be more painful and cumbersome for users.

The insurance companies generally label the limbs as “investigational” and “not medically necessary”. They also sometimes claim that there are other, less expensive and more basic limbs that will meet the user’s needs. However, the lawsuits claim that microprocessor-controlled limbs have been in use for decades and have been shown to be very beneficial to users.

The lawsuits are all asking the courts to certify them as class actions, so that other plaintiffs can join in the same lawsuit. The lawsuits are also asking that the insurance companies be forced to change their policies regarding prosthetic limbs, and that the insurance companies be forced to reimburse the plaintiffs for their damages.

If you are suffering from limb loss and your insurance company has refused to pay for your prosthetic limb, you should speak with an attorney. Call Amputation Attorney Conal Doyle at 310-385-0567. I am not only a personal injury attorney, I’m also an amputee. Call today to learn more or to schedule a free consultation.

Late last year, two amputees sued the Anthem insurance company in California, alleging that the company wrongfully failed to provide proper artificial limbs for them. The amputees asked that the company be required to pay for certain prosthetic limbs going forward, and that the company reimburse them for their prostheses.

According to the lawsuit, Anthem insurance plans exclude “investigational” services. The company defines “investigational” services as services: (1) that have progressed to limited use on humans, which are not generally accepted as proven and effective procedures within the organized medical community; or (2) that do not have final approval from the appropriate governmental regulatory body; or (3) that are not supported by scientific evidence which permits conclusions concerning the effect of the service, drugs or device on health outcomes; or (4) that do not improve the health outcome of the patient treated; or (5) that are not as beneficial as any established alternative; or (6) whose results outside the investigational setting cannot be demonstrated or duplicated; or (7) that are not generally approved or used by physicians in the medical community.

The lawsuit claims that Anthem wrongfully denied requests for microprocessor-controlled knee prostheses based on those criteria. Microprocessor-controlled prostheses use computer chips to operate a prosthetic limb. The lawsuit alleges that the limbs are not investigational and have been in use for decades.

The plaintiffs are seeking to certify the lawsuit as a class action. If you have had your claim for a prosthetic limb denied, you should speak with an attorney. Call me, Conal Doyle, Amputation Attorney, at 310-385-0567. I am currently working on several lawsuits against insurance companies on behalf of amputees, and I am happy to speak with you. Call today to learn more or to schedule a free consultation.

Anthem, a company that provides health insurance, was recently sued for refusing to provide coverage for some prosthetic devices for some of its customers. The plaintiffs are seeking to turn the lawsuit into a class action and to force the company to pay for the devices. The devices that are being excluded are microprocessor-controlled devices, which are prosthetic limbs controlled by a computer instead of by the body.

Anthem has issued medical policies to administer their claims. The plans specifically exclude coverage for any devices or services that are not “medically necessary” or are “investigational”. The insurance plans specifically label microprocessor-controlled knee prostheses as “not medically necessary” and therefore not covered unless the following four criteria have been met:

• The individual has adequate cardiovascular reserve and cognitive learning ability to master the higher level technology and to allow for faster than normal walking speed; and
• The individual has demonstrated the ability to ambulate faster than their baseline rate using a standard swing and stance lower extremity prosthesis; and
• The individual has a documented need for daily long distance ambulation and variable rates; and
• The individual has a demonstrated need for regular ambulation on uneven terrain or regular use on stairs.

The lawsuit alleges that that the criteria set forth by the company are erroneous and unreasonable. The lawsuit is asking that Anthem be required to reimburse the plaintiffs for their artificial limbs, as well as to pay for the limbs going forward.

Call me, Conal Doyle, if you have had your claims for a prosthetic limb denied. I can help. Call me today at 310-385-0567 to learn more or to schedule a free consultation on your case.

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.