Amputee Fights for Coverage of Prosthetics

Insurers Refuse to Pay

But Anthem Blue Cross and Blue Shield refused to pay for the more expensive C-Legs, because they were experimental and not medically necessary. More than 25,000 C-Legs have been used by amputees.

Susan Bailey's insurance company agreed to pay for prosthetic legs called stubbies, pictured on the...

Susan Bailey's insurance company agreed to pay for prosthetic legs called stubbies, pictured on the left. Because she had an above-the-knee amputation, though, walking with those prosthetics was painful and difficult. The insurance company refused to pay for specialized C-Leg prosthetics, right, until "GMA" went after answers.

(ABC News)

"Sometimes a treatment will be thought of as mainstream for a particular patient population, but it will be thought of as experimental for a different population," said Susan Pisano, a spokeswoman for the insurance lobbying group America's Health Insurance Plans in Washington, D.C.

Bailey said she fought with Anthem for 10 months, filing two appeals, which the company denied.

"It was tearing me up inside that I had just been told no for something that I really, really need," she said. "To live my happy life in the same way that I was living it in June 2007."

There are nearly 2 million amputees in the United States, and most health insurance policies do a poor job of covering prosthetics for them, said Patty Rosbach of the Knoxville, Tenn.-based Amputee Coalition of America, an advocacy group that works on behalf of people who've lost limbs.

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"I think that everyone assumes that if they are going to have a leg amputated or an arm amputated that it would be automatically covered by their insurance for them to get a replacement prosthesis, and I think they are absolutely astounded to find in a significant number of cases -- getting more every day -- that this is not, in fact, true," Rosbach said.

Poor Prosthetics Coverage

Rosbach said that because people don't expect to need a prosthetic limb, they don't notice the fine print on their polices limiting their coverage

"I think that you have to look at the very, very small print, and I don't think the majority of people, when they look at their policies, actually look at it word for word," Rosbach said.

Pisano of America's Health Insurance Plans said, "There are instances where employers are not purchasing the benefit to the degree that they might like."

Insurance lobbyists also argue that paying for claims like Bailey's will raise rates for everyone. At $100,000 a pair, the C-Legs are expensive.

The Amputee Coalition of America claims that insurance companies not only balk at paying for the more expensive C-Legs but also for basic prosthetic legs, which can cost as little as $12,000.

Meanwhile, Anthem Blue Cross Blue Shield refused do an on-camera interview but issued a statement saying its "medical policies are intended to reflect the current scientific data and critical thinking."