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My Insurance Company Says They Won’t Pay For My Prosthetic Because I’ve Exceeded My “Lifetime Maximum.” Is That Legal?

In prior years, it was legal for insurance companies to limit the amount they would spend on an individual’s medical care. As you can imagine, if a young child were to need an amputation and rehabilitation over a lifetime, which could include many prosthetic devices as the child grew, the lifetime maximum could be reached before the child even reached adulthood.

Fortunately for amputees, lifetime limits are becoming a thing of the past. Under the Affordable Care Act, also known as Obamacare, starting in 2014, all new insurance policies offered cannot set a lifetime maximum. For old healthcare plans which have been grandfathered into the new system, there may still be a lifetime maximum.

The new laws only apply to services and devices which are considered essential health benefits. Prosthetic devices are considered as an essential health benefit under the new law. However, some insurance companies may argue about which prosthetic device is covered as an essential health benefit. They may claim that a device which costs $5,000 is covered, but a device that costs $10,000 is not covered as an essential health benefit, even if it would offer much better care for an amputee than the less expensive option.

It’s unfortunate that many insurance companies make it difficult for amputees to pay for the services and devices they need for daily living. If you are an amputee and you are having difficulties with your insurance company, and you believe they are acting in bad faith, call Conal Doyle, Amputation Attorney at 310-385-0567. He is an amputee himself, and understands his clients’ perspectives, call today.

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