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Amputees fight caps in insurance coverage for prosthetics

SOUTH BURLINGTON, Vt. - 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.

Though 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.