Category: Amputation

United Healthcare has been sued for refusing to provide an amputee with a complex prosthetic limb. The insurance company claimed that the amputee was only able to receive the “most basic leg” that met his needs. He sued the company and is seeking to have the lawsuit certified as a class action.

The man underwent a below the knee amputation of his left leg that resulted from severe injuries he suffered in an accident in 2017. When the accident occurred, the man was in his mid-20s and was working as an account manager. He had an active lifestyle that included mountain biking, jogging and hiking.

He was referred by his doctor to a team of prosthetists for a below-the-knee prosthetic device. Because of his active lifestyle, the prosthetists recommended a below-the-knee device that included a Trans-tibial High-Fidelity Interface (socket) prosthesis. The insurance company denied the request on the basis that the device may not be the “most basic leg” that meets his needs. The company said that the man’s insurance plan will only cover the most basic artificial leg that meets his needs.

The man appealed, and the company denied his appeal. He requested that United reconsider its denial of his appeal, and the company denied his request. He then sued United. According to this lawsuit, United did not properly determine his needs, the minimum specifications for his needs, whether the man’s prosthetists was wrong about his needs, and what alternative device met his needs. Instead, the company simply issued a denial with a statement that the device was not the most basic for him.

If you are an amputee and your insurance company has denied coverage for your prosthesis, you should speak with an attorney. Call me, Conal Doyle, amputation attorney. I’m currently working on several lawsuits against insurance companies that have refused to cover prosthetic devices. Call me today at 310-385-0567 to learn more or to schedule a free consultation.

A lawsuit was filed last year against Blue Shield of California for its failure to properly pay for some prosthetic limbs, as well as for its failure to build up a network of providers who can make prosthetic limbs. The plaintiffs are seeking compensation for their losses, as well as to certify the lawsuit as a class action.

Specifically, the plaintiffs are seeking for two classes of individuals to be certified:

• All persons covered under Blue Shield of California non-ERISA health plans whose request for microprocessor-controlled foot prostheses have been or will be denied during the applicable statute of limitations as “investigational”; and
• All persons covered under Blue Shield of California non-ERISA health plans whose requests for prosthetic lower limb devices were paid by Blue Shield to out-of-network providers during the applicable statute of limitations.

According to the lawsuit, Blue Shield of California has wrongfully claimed that microprocessor-controlled foot prostheses are investigational and therefore not covered under the insurance plans. However, the lawsuit alleges that these types of prostheses have been in use for decades and are standard in the industry. The lawsuit also alleges that Blue Shield has promised its customers it would build up a network of prosthetists, and failed to do so, forcing members to go out-of-network for prosthetic limbs and resulting in large costs to them.

If you are suffering from limb loss and your insurance company has failed to properly cover your prosthetic limbs, call me, Conal Doyle, Amputation Attorney, at 310-385-0567. I can help. Call today to learn more or to schedule a free consultation.

A series of recent lawsuits filed against insurance companies in California claim that insurance companies are wrongfully refusing to provide microprocessor-controlled prosthetic limbs. The insurance companies are claiming they are investigational or “not medically necessary”, among other claims.

According to the lawsuits, microprocessor technology has been used in prosthetics for decades and has become standard in the industry. Microprocessor-controlled lower limbs feature sensors, a microprocessor, software, a resistance system, and a battery. They use technology to monitor a person’s gait using sensors. The sensors detect and monitor changes in the environment, such as going up or down a slope or walking at a different speed. Based on the feedback, the microprocessor adjusts the limb, which can enhance stability for the user, and can reduce stumbles and falls.

The lawsuits claim that the primary advantage of microprocessor technology is safety and stability, not the ability to engage in athletic endeavors. They are primarily for everyday activities of daily living and can be beneficial for virtually all amputees.

However, the insurance companies that have been sued have written medical policies that do not authorize payment for microprocessor-controlled limbs. Instead, they only authorize payment for the less-expensive body-controlled limbs, which have a number of disadvantages when compared with microprocessor-controlled limbs.

If you have had a claim for a microprocessor-controlled limb denied, you should speak with an attorney. Call me, Conal Doyle, Los Angeles personal injury attorney at 310-385-0567. I am working on several of the lawsuits and can provide you with a consultation on your case. Call today to learn more.

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.

United Healthcare, a health insurance company, has been sued for refusing to pay claims for prosthetic limbs. According to the lawsuit, the company uses its internal policies to avoid paying legitimate claims for certain types of prostheses.

The lawsuit alleges that the company refuses to pay for microprocessor-controlled limbs for its customers. Microprocessor-controlled limbs use computer chips to help operate the limb. According to studies, they are commonly used and offer users many benefits over body-powered limbs.

The lawsuit alleges that United has developed Coverage Determination Guidelines, which are written positions on whether certain medical treatments are covered or excluded under the company’s insurance plans. United has a Coverage Determination Guideline called “Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs”, which 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 for the member’s needs.

The lawsuit alleges that United has used the provision to systematically deny prosthetic arm and leg devices without property assessing or determining the individual’s functional needs and without assessing how the requested device meets the minimum specifications of the individual’s needs.

The lawsuit against United Healthcare is seeking to be certified as a class action and is ongoing. If you or a loved one has had a claim for a prosthesis denied by United Healthcare, call me, Conal Doyle, Los Angeles personal injury attorney. I’m currently working on that lawsuit and others. Call today at 310-385-0567 to schedule a free consultation on your case.

Several lawsuits have been filed against insurance companies recently for their failure to cover prosthetic limbs. The lawsuits claim that the insurance companies have wrongfully denied coverage for prosthetic limbs that are controlled by microprocessors. The insurance companies claim they aren’t medically necessary or are experimental.

There are roughly two million people living with limb loss in the U.S. About 185,000 amputations are performed in the U.S. each year. Those amputees need a prosthesis, which replaces the missing body part, such as the arm of leg. Technology improvements have allowed prosthesis manufacturers to use microprocessors to power artificial knees, feet, arms, wrists, fingers, and elbows. The alternative to microprocessor-controlled prostheses is body-powered prostheses, which can be more painful and cumbersome to use, and don’t allow users to take advantage of features offered by microprocessor-controlled prostheses.

According to the lawsuits, microprocessor-controlled arms have been in use since the 1980s and are very common today. However, many insurance companies balk at their costs, and have denied coverage to their customers.

If you have had your insurance claim for a microprocessor-controlled limb denied, you should speak with an attorney. Call me, Conal Doyle, Los Angeles Amputation Attorney at 310-385-0567. I can help. I’m currently working on several lawsuits against insurance companies for wrongfully denying coverage for prostheses. Call to learn more or to schedule a free consultation.

Late last year, three lawsuits were filed against insurance companies by individuals suffering from limb loss. The insurance companies allegedly refused to pay for prosthetic limbs that should have been covered. All three lawsuits are seeking to become class action lawsuits. It is expected that more lawsuits are to follow.

The three companies that were sued are Anthem, United Healthcare, and Blue Shield. The lawsuits were filed in California. In each of the lawsuits, two customers of the insurance company sued the company for failing to properly pay for a prosthetic limb. Each situation is different, but most involve the company claiming that the limb is “experimental” or “not medically necessary”.

Most of the plaintiffs were seeking payment for microprocessor-controlled limbs, which are limbs that are controlled by computers rather than being powered by the body. According to the lawsuits, these limbs have been around for several decades and many studies have confirmed the benefits of the limbs to the users.

If you currently are or were in the past covered by an insurance policy, and the insurance company refused to provide coverage for your prosthetic limb, you should speak with an attorney. Call me, Conal Doyle, personal injury attorney. I’m one of the attorneys working on this lawsuit and I can help. Call today at 310-385-0567 to schedule a free consultation on your case.

Two customers of Blue Shield, the insurance company, have sued the company. The lawsuit alleges that Blue Shield has a very small network of prosthetists because of its low reimbursement rates. The lawsuit further alleges that many customers of Blue Shield who are suffering from limb loss are forced to pay out of pocket for their prosthetic limbs as a result.

The plaintiffs are two men who are suffering from limb loss. One of the men was a customer of Blue Shield and in 2015 he sought help for problems he was experiencing with his prosthetic limb. He was unable to find an in-network prosthetist who could give him a suitable device. He finally obtained the services of a prosthetist, but the prosthetist was not an in-network provider with Blue Shield. Blue Shield approved a below-the-knee device for the man, but only paid 37 percent of the cost. The amputee was forced to pay $18,000 out-of-pocket for the device.

According to the lawsuit, Blue Shield’s low reimbursement rate resulted from the fact that Blue Shield did not develop a fully formed network of prosthetists. Blue Shield had very low contracted rates, which caused the vast majority of prosthetists to refuse to sign a contract with Blue Shield. The lawsuit alleges that this resulted in the plaintiff being forced to pay a large balance.

If you have been forced to pay out-of-pocket for an artificial limb even though you have insurance, call me, Conal Doyle, Los Angeles amputation attorney at 310-385-0567. I can help. I am currently working on several lawsuits against insurance companies. Call today to learn more or to schedule a free consultation on your case.

Blue Shield was sued late last year for its practice of failing to pay for some artificial limbs requested by customers. The limbs that are being denied are microprocessor-controlled limbs which are controlled by computers rather than the human body. The plaintiffs claim that the limbs have been standard for decades and that Blue Shield is acting in bad faith by denying them. Blue Shield alleges that the limbs are “experimental or investigational in nature”.

Blue Shield excludes coverage for services or supplies that are “Experimental or Investigational in Nature”. That phrase is defined as:

Experimental or Investigational in Nature – any treatment, therapy, procedure, drug or drug usage, facility or facility usage, equipment or equipment usage, device or device usage, or supplies which are not recognized in accordance with generally accepted professional medical standards as being safe and effective for use in the treatment of the illness, injury or condition at issue. Services which require approval by the federal government or any agency thereof, or by any State government agency, prior to use and where such approval has not been granted at the time the services or supplies were rendered, shall be considered investigational or experimental in nature. Services or supplies which themselves are not approved or recognized in accordance with accepted professional medical standards, but nevertheless are authorized by law or by a government agency for use in testing, trials, or other studies on human patients, shall be considered experimental or investigational in nature.

Blue Shield uses the exclusion to deny some categories of claims in a blanket fashion, including the claims for microprocessor-controlled foot prostheses. The plaintiffs claim that the prostheses are not experimental or investigational in nature, and that the insurance company is acting in bad faith by failing to pay for microprocessor limbs.

If you have had your claim for a microprocessor limb denied by Blue Shield or another insurance company, call me, Conal Doyle, amputation attorney, at 310-385-0567. I can help. Call today to learn more or to schedule a free consultation.

Two individuals who lost limbs and were customers of Anthem have sued the company, alleging that the company wrongfully labeled artificial limbs as “investigational” and therefore refused to pay for them. The plaintiffs claim that the limbs are not investigational and that the company should be forced to provide them.

In its insurance policies, Anthem does not cover services that are “investigational”. Anthem defines investigational services as:

• Services that have limited use on humans, which are not generally accepted as proven and effective procedures within the organized medical community;
• Services that do not have final approval from the appropriate governmental regulatory body;
• Services that are not supported by scientific evidence which permits conclusions concerning the effect of the service, drugs, or device on health outcomes;
• Services that do not improve the health outcome of the patient treated;
• Services that are not as beneficial as any established alternative;
• Services whose results outside the investigational setting cannot be demonstrated or duplicated; or
• Services that are not generally approved or used by doctors in the medical community.

Anthem has defined artificial limbs that are controlled by computer devices as investigational. Two customers of Anthem whose limbs were not covered by the company have sued the company and are seeking to turn that lawsuit into a class action.

If you are a customer of Anthem and your claim for an artificial limb has been denied, call me, Conal Doyle, Amputation Lawyer, at 310-385-0567. I am working on several lawsuits against insurance companies and I can help. Call today to learn more or to schedule a free consultation on your case.