Mother of Five Denied Prosthetic Knee, Sues Health Insurance Company

A mother of five sued the Anthem insurance company, claiming that the company wrongfully denied her claim for a prosthetic knee. She is seeking to turn the lawsuit into a class action on behalf of others whose prostheses were denied.

The plaintiff had her left leg amputated above the knee when she was 11 years old. She is married with five children and has insurance coverage through Anthem. In 2016, she was referred to a nationwide provider of prosthetic services, which determined that she needed a prosthetic leg with a microprocessor-controlled knee. The prosthetist sought authorization from Anthem for the leg.

Anthem denied the claim, stating that the microprocessor-controlled knee prosthesis was not medically necessary for the plaintiff, because she did not satisfy its criteria. She appealed twice. The company denied the claim, stating that in order to qualify, she must be able to walk faster than someone with a standard prosthesis. They also said she must need to walk over 400 yards a day, and the need to walk over uneven ground or to use stairs often. She also must be able to control a complex device. They found that she did not meet those requirements and therefore was not eligible for the device.

The woman sued the company, claiming it did not assess whether she met any valid criteria for receiving the device. She is asking that Anthem be required to change its policies, as well as to compensate her for the device.

There are currently several lawsuits underway involving insurance companies and their wrongful denials of coverage for microprocessor-controlled prostheses. If you have had your claim denied, call me, Conal Doyle, California amputation attorney, at 310-385-0567. I am working on these lawsuits and can help. Call today to learn more or to schedule a free consultation.