This is one of 10 stories included in the report, Voices of the Underinsured: Kansans Tell Their Stories.
Karen’s limp was noticeable. Still, she carried herself with confidence.
The 55-year-old researcher had used a prosthetic right leg since she had a below-the-knee amputation at age 11, but had maintained an active lifestyle.
Two years prior to being interviewed, Karen suffered an injury while working in her barn that fractured her right knee. Doctors told her they couldn’t surgically repair the damaged joint and recommended extending her amputation to above the knee, which meant that the prosthetic leg she had at the time would no longer fit.
Knowing what a new prosthesis costs, Karen checked her insurance plan to make sure the expense would be covered before authorizing surgery. It seemed to limit payments for prosthetics, so she called for clarification. She was informed there was an error in the contract language and that the payment cap did not apply to prosthetics.
After being assured that her insurance would cover a new leg, Karen proceeded with the amputation.
“When the [benefits] cap was removed, I was enormously relieved,” Karen said. “I’ve always been an incredibly active person and I didn’t want to lose my mobility.”
After her surgery, Karen received a temporary prosthesis to use while the swelling subsided. A temporary prosthesis is typically only worn for a few months to help an individual stay mobile and learn to walk. But Karen was forced to use hers for many months while she waited for her insurance to approve the permanent prosthesis her physician had prescribed.
As she waited, the temporary prosthesis became more and more unstable and difficult to use.
“I had waited for months for an answer and all the while my functional level went downhill,” she said. “I lost what I gained when…I was learning to walk again and undergoing physical therapy. My therapist suggested we stop because the risk of injury increased due to the temporary prosthesis being so ill-fitting.”
Not having a permanent prosthesis also affected Karen’s ability to do her job.
“I fell twice in one week,” she recalled. “I had to ask other people to do the physical part of my job.”
Since part of Karen’s research involved working with infants, the instability of the temporary leg became a work hazard.
After waiting six months for approval, Karen decided to withdraw $30,000 from her retirement savings to personally pay for the permanent prosthesis. She said her decision was prompted by growing concerns about her health and the safety issues at work.
“I was absolutely exhausted, which was [the insurance company’s] goal, to wear me out until I just gave up,” she said. “Finally, when I realized my health was in the balance, for my own health and to protect my mental and physical well-being, I bought the prosthesis myself.”
Karen had hoped that insurance would reimburse her for this expense. Her appeals were denied. The insurance company paid twice for procedures that Karen needed to ensure that the permanent prosthesis fit properly, but it continued to refuse to cover the cost of the leg itself because it featured an electronic knee component that they classified as more than a basic prosthesis.
“Of course it [the leg] wouldn’t work without those parts, like a car without a motor or a pacemaker without a battery,” Karen said. “The knee technology had been out for 10 years so it wasn’t something new and fancy. All of our service men and women use it and it’s covered by Medicaid and Medicare.”
Even though she had to purchase it herself, Karen said having the appropriate prosthesis immediately improved her mobility. But she said the physical limitations she developed from using the temporary leg had set back her recovery.
The delay affected more than Karen’s physical recovery. It also affected her mental health. She said the physical and emotional difficulties and the back-and-forth with the insurance company made her feel like “this pathetic creature out begging for a leg with a tin cup.”
Policy Note:
Karen works for an employer that is self-insured. A self-insured plan is when an employer holds all the financial risk, collects premiums and puts those funds in a pool to pay for medical expenses. The employer might contract with an insurance company to manage the administrative aspects of the plan; therefore, employees may not realize that they are a part of a self-insured plan.
Many insurance policies, like Karen’s, cover certain medical services or equipment while denying others. Federal health reform calls for four tiers of comprehensive coverage. However, it is unclear to what extent even comprehensive coverage would ensure payment for certain types of medical equipment. Even if the new law requires coverage for the medical equipment Karen needed, it is likely that many of the provisions in federal health reform will not apply to self-insured health plans like Karen’s.