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My Prosthetist Tells Me That I’m A Good Candidate For The Genium Knee From Ottobock, But My Insurance Company Says It’s Not Covered. What Are My Rights?

The Genium knee from Ottobock is an amazing prosthetic leg. It allows its users to walk up stairs normally, to walk forwards and backwards easily, to sit normally, and to stand easily. It’s water resistant and has a long battery life. However, it’s more expensive than many other prosthetics.

It’s unfortunate that insurance companies often choose their profits over a patient’s comfort and safety. Many insurance companies do not cover more expensive prosthetics, arguing the less-expensive prosthetics are sufficient. If your insurance company initially says the Genium knee from Ottobock, or any other prosthetic isn’t covered, don’t give up. There are actions you can take to increase the odds that the prosthetic will eventually be covered.

First, you need to be organized, keeping all documentation relating to your medical condition and your medical treatment together and organized. This will make it easier and prevent delays if your insurance company asks for additional information. You should also work closely with your health care team. Often, in order to receive funding for a prosthetic, you need to show there is a medical necessity. A physician can help by giving you a prescription for the device you need.

You should also take time to understand your insurance plan. Your insurance plan’s Summary of Benefits will provide info on what is covered, as well as your deductible, out-of-pocket amounts, the amounts covered for prosthetics, and whether there are any lifetime caps. If you discover that something you need isn’t covered, don’t give up. Talk to your health care team, as other sources of funding could be available. If your insurance company continues to deny your request, file an appeal. Find out why the claim was denied, and see if there’s anything you can do. If the claim was denied because of improper documentation or because the device was not medically necessary, gather the correct documentation needed.

If your insurance company continues to deny your claim, they may be acting in “bad faith”. Insurance companies have a duty to act in good faith and not to deny legitimate claims. If your insurance company is found to be acting in bad faith, you may be entitled to additional damages, in addition to the amount of the unpaid claim.

If your insurance claim for a prosthetic device has been denied, call Amputation Lawyer Conal Doyle at 310-385-0567. As an amputee himself, he enjoys helping amputees obtain the benefits to which they are entitled. He has also helped clients across the U.S. with insurance claims for microprocessor prosthetic legs. Call today to learn more.

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