Recently, two individuals who have suffered lower limb loss sued Anthem, a health insurance provider, for its failure to pay for lower limb prostheses under the insurance plan. The plaintiffs are seeking to certify their lawsuit as a class action.
In particular, the plaintiffs are suing Anthem because of its failure to provide microprocessor-controlled lower limb prostheses under the terms of the insurance plan. Anthem claims that it is not legally required to pay for those prostheses because under the terms of the policy, they are not medically necessary.
Anthem uses four criteria that must be met in order to pay for prostheses. First, the individual must have adequate cardiovascular reserve and cognitive learning ability to master the technology and to allow for faster than normal walking speed. Second, the individual must have demonstrated the ability to ambulate faster than the baseline rate. Third, the individual must have a documented need for daily long-distance ambulation at variable rates. Finally, the individual must have a demonstrated need for regular ambulation on uneven terrain or regular use of stairs.
The plaintiffs claim that all of the criteria that Anthem uses are erroneous. The plaintiffs claim that the first two criteria may allow a person with limb loss to walk faster, but that’s only one benefit of the device. They claim the third and fourth criteria are unreasonable.
The plaintiffs are asking the court to require Anthem to compensate them for microprocessor-controlled prostheses, as well as to change its policies going forward. If you or a loved one has had a claim denied by Anthem for a microprocessor-controlled prosthesis in California, call me, Conal Doyle, at 310-385-0567. I’m one of the attorneys involved in the lawsuit, and I can help. Call today to learn more about the lawsuit.