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.