My New Leg

I have yet to see Michael Moore’s movie, “Sicko”, but I’ve read that it does a fair job of pointing out how our health care system is broken. Amen to that. While getting a new prosthesis, courtesy of my old insurance company, I have been applying for new health insurance. Sometimes we focus on the technology and forget that the access to this technology is very regulated and expensive.

I’ve received a couple letters from my prospective insurance company which I feel are worth relating here as an illustration of some of the hoops that people with disabilities have to jump through in order to get health care — and particularly insurance that will pay for prostheses and other necessary assistive technology.

But, first, some background on how this all works. In my first post, I briefly described how…

I need to get a prescription from a physician. Then I need to bring the prescription into Wayne’s shop and give it to Julie, the head admin assistant who handles billing — and pretty much everything except for actually making the leg, really. Julie will use the prescription to seek authorization from my health insurance, and get their assurance that they’ll reimburse Wayne for the cost of making my prosthesis. Essentially, Wayne makes me the prosthesis, bills my health insurance, and they pay for the leg. Given that an appropriate prosthesis for an active amputee such as myself can cost in the ballpark of $7-8,000, this is one of the more important, albeit boring, parts of getting a new leg.

Well, that’s all pretty straightforward, and my current insurance company authorized my new leg without any hassles whatsoever. Well, nothing worth mentioning, at least.

But my prospective new insurance company has not given me such a smooth ride. When I applied for their insurance I had to note my amputation as a pre-existing condition on the application form. They have since sent me a couple letters which I believe suggest they are looking for documentation that will relieve them of having to pay for any prosthetics care for me.

The first letter I received asked me:

Do you wear a prosthesis? If so, when was it last replaced? When were you advised to have it replaced again?

Translation: Do you wear a prosthesis? Did your last insurance company recently pay for a replacement? If not, do you plan on getting it replaced anytime soon and actually expect us to pay for it?

A week later, I received a second letter. It instructed me to:

Provide evidence of having obtained new prosthesis and good fit and that you have been released from further follow-up by your physician.

Translation: In your response to our previous letter, you said you are currently getting a new leg. We don’t believe you. Prove to us that you’ve recently had your prosthesis replaced AND that you won’t pester our providers with follow-up appointments. In fact, have your doctor write us a letter to that effect so if you do need further prosthetics care in the future, we’ll have the documentation necessary to deny your claim. And if you don’t provide us with documentation to help us deny you future benefits, we may deny you coverage.

Classy, huh?