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Addressing Discrimination in Medical Insurance Coverage for Amputees

This legal question related to legal consultants-medical in PickensSouth Carolina has been answered.

Location: Pickens  |  Law type: legal consultants-medical

Is there a lawyer who can help myself and others with medical insurance policy coverage being disabled and our rights  

I want to know my rights on how to get these policies with insurance changed. There’s so many amputees that  give up on walking because all these companies (no matter what you pay) won’t cover the prosthetics (Medicare and prosthetic devices) that hands down would allow so many the ability to walk. I’m an amputee for 13 yrs i feel discriminated against for I was told by my insurance company that they never covered my knee when in fact they did and have papers to show they did. Even with drs telling them I need this particular knee as the other one is worn out and I had revision surgery.  they now refuse saying they never did cover it. I appealed internally and externally denied. They said it’s a Luxury. Since when did needing a particular device to walk become a luxury.  I walk 3-5 miles a day. I’m now faced with the fact of after learning to walk again that I may not be able to very much longer because I can’t afford this knee out of pocket. That I will be in a wheelchair because someone decides what I need to walk is a luxury. They will cover a $27,000 knee that I fell with every other day and can’t go back to because you can’t trust it at all. It also risk more injury. I also went through one of those every year and half. I fell with my son at 8 months one time busted my knee and elbow up protecting my son.

That's when someone graciously gave me the other knee from a man that just passed away. I also have two titanium rods in my spine that put me in a very bad situation when it comes to walking and falling. These knees run around $60,000 but last 3-5 yrs and don’t let you fall because they have microprocessor that’s programmed to you. You can actually trust this device and therefore don’t give up because you fell down. They lead you to continue life and prosper instead of on the ground depressed and give in to sitting in a wheelchair thinking you just can’t do it because the insurance that you pay for won’t help cover what you need to confidently walk again. Because it’s a luxury. On the other hand I had done a pre-authorization a day of physical therapy assessment that the insurance did cover a new knee years ago when the knee given to me worn out.  After my revision surgery the drs said it was time for a new knee and that’s when they denied it and denied that they had ever covered it before. I have also been told that they won’t cover a socket (part around the actual limb) that is adjustable- it cost $7000 cash. It is more open concept allowing muscles to form to have more control and protect the nerves that cause so many pain every day. But they will pay for the one that is solid plastic that doesn’t breath and you have to have a new one made if you gain a pound or loose a pound , it also cost $7000 It too is a luxury.

There is more to this problem with insurance though.

I just want to know can I or we obtain a lawyer to fight for our right for the ability to walk? Or continue to walk and the right to have services provided to lessen our pain that doesn’t have anything to do with medication but physical abilities with the anatomy in my case and many others. I have asked when selecting my insurance of what was covered as far as this concern and was told they didn’t know what the details of that would be as to if they covered the device I need to continue to walk. Pretty sure they should have a recording of her stating that. Therefore I was uninformed while signing up for the policy of the coverage even though I really had no choice but stuck with the one and only company for coverage if I was to get a subsidy. Are they not supposed to be able to help me with that information before I sign up for the policy? I had no option to look anything up because they had me on the phone after I had tried signing up before the deadline and had to leave my name for them to call me after the deadline. Are they not supposed to make me whole again regarding coverage ? If they won’t provide me with this device I am not whole, they say I don’t deserve to walk because something would cost more in the beginning cheaper in the long run but last longer it means it’s a luxury?  

Do you consider your type of shoe with an arch in it a luxury if it helps you walk better? This is the well being of someone’s capabilities mentally and physically that they are withholding services of preexisting conditions that won’t ever change. The ability to walk. None of us ask to be like this or want to be like this I feel they are putting a label that we don’t deserve to walk or have the devices we need because we are less than normal people. That our disability of not being whole means we should just give up on walking, living and be ashamed to confine ourselves to a bed or chair with no job mooching off the government more than needed because it’s too much to provide services we pay a monthly premium for because they are judgemental deciding if we deserve the right to walk even if it saves them money in the long run being I can’t ever get better and grow a leg back to just be wasting the money spent. Makes no sense other than discrimination to me. 

Quick reply - medical insurance policy coverage (prosthesis):

Under the health care law, plans must cover treatment for pre-existing conditions from the first day of coverage. 

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Commonly posted questions...

Medical Malpractice and Abandonment: Seeking Redress
1 year 10 months ago, legal consultants-medical, Toms River

Legal Solution

The response provided below is specific to legal consultants-medical in the jurisdiction of Pickens. If the response is inadequate, please submit a detailed inquiry.

Addressing Discrimination in Medical Insurance Coverage for Amputees

In today's society, the right to access essential medical devices and services should not be considered a luxury but a basic human right. For many amputees, these devices are crucial not just for mobility, but for their overall well-being. When insurance companies refuse to cover necessary prosthetic devices, it raises concerns of discrimination, uninformed policy selections, and a blatant disregard for the quality of life of the insured.

Relevant Regulations and Legal Frameworks:

  • The Affordable Care Act (ACA): Provides protections against insurance discrimination based on pre-existing conditions.
  • Americans with Disabilities Act (ADA): Prohibits discrimination based on disability in various public and private sectors.
  • Patient's Bill of Rights: Highlights the rights and protections for insured individuals.
  • Medicare Policies: Guidelines about the coverage of prosthetic devices for eligible beneficiaries.
  • Government Health Insurance Website

Potential Solutions:

  1. Legal Action: Engaging a personal injury lawyer or a lawyer specialized in medical insurance disputes could be beneficial. They can help address the claims of discrimination and breach of contract.
  2. External Appeal: If the internal appeal fails, the decision can be taken to an independent third-party for review. Their decision will be final.
  3. Public Awareness: Launching a public awareness campaign can put pressure on insurance companies. Sharing personal stories can shed light on the systemic issues facing amputees.
  4. Legislative Push: Engage local and state representatives to advocate for more comprehensive insurance coverage legislation.
  5. Explore Other Insurance Options: It's crucial to compare lawyers in your area and seek assistance in finding a policy that provides the needed coverage.

Cost Analysis for Legal Assistance in Pickens:

Service Average Cost ($)
Initial Consultation 210
Legal Research 320 per hour
Drafting Legal Documents 470 per document
Representation in Mediation 2,900 per session
Full Legal Representation in Court 15,420 per case

Note: The costs provided are average estimates based on typical legal fees in Pickens. Actual costs can vary based on the complexity of the case and the specific attorney or law firm selected.

Clarification Needed:

Your situation indeed sounds challenging, and understanding all aspects is crucial for a comprehensive solution. Before proceeding, it would be beneficial to get more specifics on the policy terms and any communication or documentation from the insurance company.

Take the next step! You deserve to have your rights protected. Find the right lawyer and advocate for the quality of life you're entitled to.

Relevant Questions:

  1. Documentation: Do you have all the written communications and denials from the insurance company?
    • Explanation: Keeping a record of all interactions with the insurance company can serve as evidence in a legal case.
  2. Policy Terms: Have you thoroughly reviewed your insurance policy to determine what is explicitly covered and what is not?
    • Explanation: Understanding policy terms is crucial in identifying potential breaches of contract.
  3. Witnesses and Experts: Are there medical professionals willing to testify on the necessity of the specific prosthetic devices for your well-being?
    • Explanation: Expert testimonies can strengthen the case, showcasing the genuine need for the denied devices.

Frequently Asked Questions:

What are my rights when an insurance claim is denied?

The insured individual typically has the right to an internal appeal within the insurance company. If this fails, an external appeal can be made to an independent third-party.

Can insurance companies change what they cover while I'm still under contract?

In most cases, insurance companies cannot alter the terms of a contract mid-way without informing the policyholder, and even then, there are restrictions.

How do I prove the medical necessity of a device?

Medical documentation, expert opinions, and testimonies from healthcare providers can help prove the necessity of a particular device or treatment.

Is it considered discrimination if specific devices aren't covered?

It might be, especially if the denial leads to a disproportionate negative impact on individuals with disabilities, violating laws such as the ADA.

What should I look for in a lawyer to help with my case?

Experience in medical insurance disputes, knowledge of disability rights, and a track record of successful advocacy are crucial factors to consider when searching for the right lawyer.


This content is for informational purposes only and does not establish an attorney-client relationship. It's always recommended to consult with a local attorney about your specific situation.

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