Amputees fight caps in coverage for prosthetics

By DAVE GRAM
Associated Press Writer

SOUTH BURLINGTON, Vt. (AP) -- After bone cancer forced the amputation of her right leg below the knee, Eileen Casey got even more bad news: Her insurer told her that she had spent her $10,000 lifetime coverage limit on her temporary limb and that the company wouldn't pay for a permanent one.

"It was shocking to find out I was going to have to take out a loan to buy myself a leg so I could keep working and living independently," Casey said. At the bank, she said, she burst into tears when they asked what the loan was for.

Since then, Casey has joined a nationwide fight by amputees and the prosthetics industry to get the states and Congress to require fuller coverage for artificial limbs. The insurance industry is fighting the effort, saying such mandates drive up costs and reduce the flexibility customers want.

"The cumulative effect of several mandates can price employers out of the market altogether," said Mohit Ghose, who was a spokesman for America's Health Insurance Plans, an industry lobbying group, when he was interviewed recently for this story. He left the organization three weeks ago.

Vermont Gov. Jim Douglas recently signed into law a bill making Vermont the 10th state to require insurance companies to cover prosthetics as fully as they do other medical procedures. A similar measure is pending in Congress.

These laws say that if an insurance policy covers, say, 80 percent of the cost of any other medical procedure - whether a doctor's office visit or open-heart surgery - it must do the same for prosthetic limbs.

Just under 2 million Americans have lost a limb, with the largest number of amputations due to diabetes, said Paddy Rossbach, president and chief executive of the Amputee Coalition of America.

Simple prosthetic limbs range in cost from about $3,000 to $15,000. Those that are more mechanically advanced, or come with embedded computer chips, can cost up to $40,000. Expenses can grow further because many patients need new artificial limbs or sockets when the stump to which the prosthetic arm or leg is attached shrinks or otherwise changes shape. This is especially a problem in children.

While many private insurers have strict limits on the devices, government programs tend to be more generous. Medicare, the government health insurance program for the elderly, covers 80 percent of prosthetic costs and, unlike many private insurers, does not consider the more expensive mechanical or computerized limbs to be experimental.

The Veterans Affairs Department, which is seeing a growing number of amputees returning from Iraq and Afghanistan, provides prosthetic care without limits, said VA spokesman Terry Jemison. Anyone eligible for VA benefits - from a young soldier wounded in combat to an older veteran who has developed diabetes late in life - "will receive the latest in technology without limits on cost," Jemison said.

Rossbach argues that the health insurance industry's talk of mandates driving up costs is overblown. She said studies in six states that have passed these laws showed that increased coverage for prosthetics had added 12 to 25 cents a month to the average insurance premium.

She added that insurance companies' slowness to cover prosthetics can increase other health care costs in the long run, because patients' immobility often leads to other ills.

"If people have a very sedentary life, then they are going to be at risk for secondary conditions - diabetes, obesity, depression, some forms of cancer," Rossbach said.

Still, mandates are not the answer, America's Health Insurance Plans argues.

"Mandates misallocate resources by requiring consumers - or their employers - to spend available funds on benefits that they would otherwise not purchase," it says on its Web site. "They also limit consumer choice by not allowing health insurance plans to make innovative and efficient products available to employers and individuals, including mandate-free policies."

Many health insurers lump prosthetics under the category of durable medical equipment, which includes less-expensive items such as crutches and back braces. Many people do not realize until it is too late that they have signed up for coverage limits that won't come close to paying for prosthetics, Rossbach said.

To Casey, who sells advertising for a Burlington-area TV station, the result seems arbitrary and unfair.

"If I had breast cancer and had a double mastectomy, they would cover breast reconstruction, yet I can't have a leg? This makes absolutely no sense," she said.