If I Have Submitted An Insurance Claim For A New Microprocessor Prosthetic Leg, The C-leg, But My Insurance Company Has Denied The Claim, What Are My Rights?
This depends on a few things. The first thing you need to do is to get a copy of your insurance policy, which is the Evidence of Coverage, or “EOC.” Request it in writing from your insurance company. It is the document that will govern your claim; it is a contract between you and the insurance company. There are two important sections of your policy.
The first is the section that identifies what medical needs are “covered.” The second is the section of the policy that tells you about “exclusions” or what is not covered. These two sections need to be read together and are often confusing, vague, and ambiguous, even for lawyers. The first section “giveth” and the second section “taketh away.”
In other words, the “coverage” section should tell you if prosthetics are covered, but the “exclusions” section may have a specific exclusion for “microprocessor knees” or contain other limitations on the type of prosthetic coverage available.
Oftentimes, insurance policies don’t expressly tell you that certain prosthetics are “excluded.” Rather, the insurance company will, after the fact, deny coverage and rely on some “catch all” provisions in your policy, like “medical necessity” or argue that the device is “experimental or investigational.” All health insurance policies have these exclusions.
However, the policy doesn’t define what is “experimental or investigational” or what criteria are used to determine whether a service is “medically necessary.”
Instead, the insurance companies decide whether a claim meets this criterion, and where do you think the insurance company’s economic incentive lies? Insurance companies make more money when they deny claims. They also know that few people have the knowledge and/or resources to consult an attorney and fight for their rights.
Many insurance companies have official written policies on microprocessor knees, for example. However, these policies are not part of the EOC and are never given to you. They are not binding or legally enforceable, although the insurance company will imply that they are, and suggest, or even outright represent, that they bar your claim. This is a typical and dishonest attempt by the insurance company to put corporate profits ahead of your health.
An insurance company has a duty to act in good faith and not deny claims to simply increase corporate profits. An insurance company has a duty to put your interests ahead of corporate greed, yet they rarely do. Don’t accept “no” for an answer from your insurance company. Fight back. If your claim for prosthetic benefits has been denied, you may have a “bad faith” claim against your insurance company.
You may be entitled to “bad faith” damages in addition to forcing your insurance company to pay the claim and provide you a prosthetic limb. For example, in the last three cases our firm has handled, we recovered $750,000, $275,000, and $250,000 for clients who had their claims for prosthetic benefits denied.
I have helped clients across the United States with insurance claims for microprocessor prosthetic legs and welcome the opportunity to hear more about your specific issues. Please contact me, Amputation Injury Lawyer Conal Doyle, today for a free, no obligation consultation at 1-310-385-0567.