Insurance denies amputees limbs

J. Douglas Call

Call is the president of Virginia Prosthetics Inc. in Roanoke, the largest orthotic and prosthetic provider in Southwest Virginia.

"Believe in your possibilities."

That's what I tell patients I see for the first time who have recently lost a limb to amputation. For most patients it's not what they want to hear, and understandably so. Limb loss, whether it's the result of an accident or disease, is a traumatic, life-changing event.

Regardless if the new amputee sitting in front of me is a 17-year-old long-distance runner or a senior citizen who's an active gardener, the reaction is invariably the same. They're skeptical their life can ever be good again -- let alone believe that, with the proper treatment, they'll be able to do the things they once loved, like run a marathon or tend to their garden. But in time, most become believers and realize their possibilities, thanks to continued advancements in the field of prosthetics, experienced and compassionate practitioners, individual determination and a strong family support network.

So imagine my frustration, and more important my patients', when I have to tell some amputees the following: "I have the expertise and technology to fit you with a prosthesis that will help restore the active, fulfilling lifestyle you knew before the amputation, but your insurance policy won't pay for treatment because your insurer either doesn't cover prosthetic care or has reduced its coverage significantly."

In these situations, which are happening with increasing frequency, we still treat the patient because we don't believe in turning anyone away, even if their insurer won't cover the treatment. Previously, we've donated tens of thousands of dollars in treatment and materials to patients, and I'm sure that we will continue to do so.

However, we are not a nonprofit organization and the alarming changes we are witnessing among insurers when it comes to covering prosthetic care threaten our continued ability to treat patients unless changes are made.

Amputees in Virginia today face the grim reality that a growing number of group and private insurance companies are imposing unrealistic caps on prosthetic coverage or are eliminating coverage altogether. Depending on the amputee's level of activity and type of amputation, a prosthesis can cost anywhere from $5,000 to upwards of $40,000. Some insurers force their insureds to accept policy limitations, such as one limb per lifetime, a $2,500 maximum lifetime benefit or a $500 limit on treatment per year.

Unbelievably, some companies are even eliminating prosthetic coverage altogether. There is no consistency among insurers when it comes to prosthetic coverage and there needs to be.
Several states, including Colorado, Maine, New Hampshire, Rhode Island, Massachusetts and California, have already recognized this problem and passed legislation requiring insurance companies to pay for prosthetic care.

In Virginia, a concerned group of patients, orthotic and prosthetic providers, legislators and the Amputee Coalition of America have joined forces under the banner of WAVE, Working Amputees of Virginia for Equality. Together, we are supporting Senate Bill 931, prosthetic parity legislation that requires health insurance companies to provide coverage for the repair and replacement of prosthetic devices and components.

This draft bill is presently before Virginia's Special Advisory Commission on Mandated Health Insurance Benefits, whose members will decide this fall whether the bill dies or takes the next step toward becoming a reality. Commission members should allow this bill to move forward, especially in light of the facts.

Mandating prosthetic coverage can actually save the commonwealth money through cost savings in unemployment insurance, state employment and training programs, rehabilitation and counseling programs and other social welfare systems. According to the coalition, it is estimated that every dollar spent on rehabilitation, including prosthetic care, saves more than $11 in disability benefits. The fiscal savings that result from legislation requiring prosthetic coverage pale in comparison to the nonfiscal benefits that accompany mandated prosthetic coverage.

Amputees who have access to prosthetic care and devices show a reduction in the secondary conditions caused by a sedentary lifestyle, have decreased dependence on caretakers and a reduced chance of diabetic-related complications leading to additional limb amputation.
Most important, this segment of the population can become contributing members of society again instead of being dependent on it.

I urge the commission to allow a prosthetic parity bill to move forward and the nearly 40,000 Virginians living with limb loss or limb deficiency to once again believe in their possibilities.