Category: Amputation

Blue Shield of California, the insurance company, was sued late last year. The plaintiffs claimed that Blue Shield’s policies on coverage for prosthetic limbs are incorrect, and the lawsuit is seeking compensation for individuals whose claims for prosthetic limbs have been wrongfully denied.

According to the lawsuit, Blue Shield has developed a medical policy called “Microprocessor-Controlled Prostheses for the Lower Limb”. The policy states that microprocessor-controlled feet are considered investigational. However, according to the lawsuit, the medical policy misstates the studies regarding microprocessor-controlled foot prostheses.

The lawsuit claims that there is ample evidence about the effectiveness of microprocessor-controlled foot prostheses. The feet respond to feedback from the sensors based on walking speed, incline, decline, and type of terrain. They allow a more normal bend at the ankle, to allow for better balance. They create better stability and reduce falls. They also result in less pain for the user. According to the lawsuit, the benefits of microprocessor-controlled feet have been well-documented and are known to Blue Shield.

The lawsuit is seeking additional plaintiffs who have been harmed by Blue Shield’s failure to provide microprocessor-controlled foot prostheses. If you have had your request for such a device denied by Blue Shield, you should speak with an attorney. Call me, Conal Doyle, Los Angeles personal injury attorney at 310-385-0567. I am involved in the lawsuit against Blue Shield and we would be happy to speak with you. Call today to learn more or to schedule a free consultation on your case.

Two individuals who suffered limb loss recently sued Blue Shield of California, claiming their prostheses were not properly covered under the terms of the insurance policies. One member had his claim for a microprocessor-controlled prosthesis denied by the company. The other member had to use an out-of-network prosthetist and had to pay extensive out-of-pocket costs due to the lack of availability of in-network prosthetists.

Those two individuals sued Blue Shield and are seeking to make the lawsuit a class action lawsuit. In the case, the plaintiffs are asking that Blue Shield be forced by the court to take five actions. They are: 1. Stop its practice of denying all requests for microprocessor-controlled foot prostheses; 2. Notify class members that its decision to categorically deny all requests was incorrect and that all previously denied requests will be re-reviewed; 3. Re-review all previously denied requests for microprocessor-controlled foot prostheses in a proper manner; 4. Notify class members that if they have paid out-of-pocket for denied microprocessor-controlled foot prostheses, they can submit those claims for review; and 5. Review any such claims received in a proper manner.

If you have suffered from limb loss, and Blue Shield of California failed to pay for your prosthetic limb, call me, Conal Doyle, Los Angeles personal injury attorney, at 310-385-0567. My team can help. Call today to schedule your free consultation.

Late last year, three lawsuits were filed against three separate health insurance companies for their failures to pay for microprocessor-controlled prosthetic limbs. The three health insurance companies that were sued are Anthem, Blue Shield of California, and United Healthcare.

All three insurance companies have denied coverage for microprocessor-controlled limbs for their customers. The insurance companies typically claim that they are investigational, not medically necessary, or that the insurance company is not obligated to pay for those limbs when cheaper limbs are available.

Microprocessor-controlled limbs use microprocessors to power the artificial limbs. Manufacturers have developed lower leg devices that are much more similar to the movements of real legs, which can minimize falls, allow walking on uneven terrain, and can result in much less pain for the user. Microprocessor-controlled upper limbs have much better comfort and functionality. They are essential for anyone who needs to move their hands with dexterity, grasp objects, or perform other necessary tasks of daily living.

However, microprocessor-controlled limbs are much more expensive than more basic limbs. Therefore, many insurance companies deny coverage for them. If you have had an insurance company deny coverage for a microprocessor-controlled limb, you may be eligible to join one of these lawsuits or file your own. Call me, Conal Doyle, amputation attorney, at 310-385-0567. I am working on these lawsuits and my team can help. Call today to learn more.

Two people who suffered from limb loss and who were covered by Anthem health insurance company sued the company because it failed to provide certain prostheses. The company labeled microprocessor-controlled knee and foot-ankle prostheses as “investigational” and refused to provide coverage.

As of the time of filing the lawsuit, the company labeled all microprocessor-controlled foot-ankle prostheses as “investigational and not medically necessary for all indications. Under the terms of the insurance policies issued, the company is not responsible for paying for medical devices and treatments that are investigational.

The company labels “investigational” services as services that meet one of seven criteria: 1. Services that are not generally accepted as proven or effective procedures within the organized medical community; 2. Services that do not have final approval from the appropriate governmental regulatory body; 3. Services that are not supported by scientific evidence which permits conclusions concerning the effect of the service, drugs, or device on health outcomes; 4. Services that do not improve the health outcome of the patient treated; 5. Services that are not as beneficial as any established alternative; 6. Services whose results outside the investigational setting cannot be demonstrated or duplicated; or 7. Services that are not generally approved or used by doctors in the medical community.

If you have had a claim for a prosthesis denied by Anthem, call me, Conal Doyle, Los Angeles personal injury attorney, at 310-385-0567. Our team is working on the lawsuit, and we are seeking additional plaintiffs. Call to learn more or to schedule a free consultation.

A lawsuit filed against Blue Shield of California, an insurance company, is seeking to be certified as a class action lawsuit. A class action lawsuit is one in which multiple individuals with similar complaints against the same defendants can join together in one large lawsuit instead of being forced to bring individual lawsuits.

Two individuals who have suffered from limb loss are bringing this lawsuit against Blue Shield. One of the individuals had an amputation of his left leg and sought authorization from Blue Shield for a microprocessor-controlled foot prosthesis. Blue Shield denied the claim on the basis that a microprocessor-controlled prosthesis is always investigational and therefore excluded. The other plaintiff was forced to pay a large amount of money for his prosthesis after he was unable to find an in-network prosthetist and had to use an out-of network prosthetist.

The lawsuit is seeking certification of two classes of individuals. The first is everyone covered under Blue Shield of California’s health plans whose requests for microprocessor-controlled foot prostheses have been denied. The second is everyone covered under Blue Shield of California’s health plans whose requests for prosthetic lower limb devices were paid by Blue Shield to out-of-network providers.

If you fall into either of those categories, call me, Conal Doyle, Los Angeles personal injury attorney. I am one of the attorneys working on the lawsuit, and I can help. Call my office today at 310-385-0567 to learn more or to schedule a free consultation on your case.

The mother of a 12-year-old boy who was denied coverage for a certain type of prosthesis sued the United Healthcare, the insurance company that denied coverage. The lawsuit is seeking other plaintiffs who have had their requests for prostheses denied by United Healthcare.

The boy suffers from a congenitally-acquired absence of his right forearm and hand. As he grows, he requires both hands to perform everyday functions as an active 12-year-old boy. A prosthetist recommended that he be given a microprocessor-controlled device which simulates a human hand by providing the six fundamental grips of the human hand. United Healthcare denied the request for the device on the basis that the device exceeded the minimum specifications for the boy’s needs.

The boy’s mother appealed to the insurance company, and the denial was upheld on the basis that the prosthesis included many features that exceeded the boy’s basic needs. The boy’s doctor wrote him a new prescription, and the boy’s prosthetists put together a new written order for a cheaper prosthesis. His prosthetists also provided further documentation explaining why a basic prosthesis did not meet the boy’s needs. The new claim was also denied.

The boy’s mother is suing United Healthcare, claiming that the company did not properly assess his needs, and failed to provide any facts or reasons supporting the denial. The lawsuit is seeking to be a class action and is looking for other plaintiffs whose claims for prostheses were denied. If you have had a claim for a prosthetic device denied by your 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.

Two people suffering from limb loss sued Anthem, a health insurance company. According to the lawsuit, Anthem wrongfully denied coverage for all devices, claiming they are “investigational and not medically necessary for all indications”. The plaintiffs claim that the devices are not investigational and are necessary for people who have limb loss.

According to the lawsuit, microprocessor-controlled foot-ankle devices use technology to simulate the movements of a normal foot and ankle. They respond to constant feedback from sensors to the microprocessor. The microprocessor then changes the resistance to downward motion and upward motion of the foot based on incline, decline, walking speed, and terrain. The microprocessor makes adjustments in real time. This helps to create stability, decrease stumbles and falls, improve ambulation, and decrease the discomfort and pain associated with a prosthesis.

The lawsuit claims that microprocessor controlled lower limb prostheses are accepted by the medical community as standard. They are routinely prescribed for individuals who meet appropriate medical criteria. The lawsuit claims that Anthem’s claim that the devices are investigational and are not medically necessary is false.

If you have had a request for a prosthetic device denied by Anthem, you may be eligible to join the lawsuit, which is currently ongoing. Call me, Conal Doyle, Los Angeles personal injury attorney at 310-385-0567. My team can help. Call today to learn more or to schedule a free consultation.

Two customers of United Healthcare, a health insurance company, sued the company for providing only minimum prostheses to its plan members. The plaintiffs are seeking compensation for their prostheses as well as seeking other plan members who have had claims for prostheses denied to join the lawsuit.

One of the customers was an active man in his 20s. He worked as an account manager and had an active lifestyle with hobbies that included jogging, hiking, and mountain biking. Because of his lifestyle, prosthetists recommended that he be given a below the knee device that included a Trans-tibial High-Fidelity Interface (socket) prosthesis. United Healthcare denied the request for the device, claiming that the device may not be the most basic leg that meets his need. According to the terms of the policy, the health care plan will only cover the most basic artificial leg that meets the amputee’s needs. The customer appealed, and the appeal was denied twice.

The other customer was a 12-year-old boy, who also had an active lifestyle. He was born without a right forearm and hand. He needed both hands to perform everyday functions like eating, grooming, typing, playing his trumpet, and more. A prosthetist recommended that he be given an i-limb quantum device with a High-Fidelity socket. It’s a powered device with articulating fingers that simulates a human hand. United denied the request for the device on the basis that the device exceeded the minimum specifications for the boy’s needs. His mother appealed and it was denied.

The two customers sued United Health Care, claiming that the company did not properly assess or determine the customers’ functional needs, the minimum specifications for the customers’ needs, and what alternate prosthetic devices met the customers’ needs. They claim that United failed to provide any facts or reasons supporting the denials.

The two plaintiffs are seeking that the company be forced to pay them for their prostheses, and that the company be required to clarify legal right for benefits under the plan. If you are a customer of United Healthcare and you have had a claim for a prosthesis denied, 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.

Two amputees recently sued Blue Shield of California, a health insurance company. One of the men had a leg amputation in 2011. In 2016, he needed a new prosthetic device, and sought authorization from Blue Shield for a microprocessor-controlled foot prosthesis. The request was denied.

The other plaintiff had an amputation in 2009, and in 2015 he needed a new prosthesis. He was unable to find an in-network prosthetist who could give him a suitable device and was forced to pay large amounts out-of-pocket for the device.

The plaintiffs are seeking to make their lawsuit a class action and are asking that two classes of individuals be certified in the class action. The first is all people who are covered under Blue Shield of California non-ERISA health plans whose requests for microprocessor-controlled foot prostheses have been or will be denied. The second is all people who are 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 statute of limitations.

If you have suffered limb loss, and you were a customer of Blue Shield of California, and you either had your request for a prosthesis denied or you had to visit an out-of-network provider, call me, Conal Doyle, Los Angeles personal injury attorney, at 310-385-0567. I am one of the attorneys working on the lawsuit, and I can help evaluate your legal options. Call today to learn more or to schedule a free consultation on your case.

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.