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.