sun editorial:

Coverage cap unfair

Health insurers should cover prosthetics as they do other medical needs

Friday, June 13, 2008 | 2:08 a.m.

Americans who have lost a limb and require a prosthetic substitute say many private insurance plans don’t cover such devices, forcing patients to raise thousands of dollars to pay the cost themselves, or, more likely, go without.

One woman, who lost a leg to bone cancer, told the Associated Press her insurance company refused to pay for her permanent prosthetic because her policy’s $10,000 lifetime coverage limit had already been spent on the temporary prosthetic, which she was given to use until the permanent one was ready.

A prosthetic limb can cost from $3,000 to $40,000, depending on the technology. And one often doesn’t last a lifetime. Children need replacements as they grow, and adults need replacements when changes occur in the area of the body to which the device is attached.

Congress is considering legislation that would require insurers to cover prosthetics in the same manner they cover other medical procedures and devices. For example, if a policy covers 80 percent of a patient’s medical services, that policy also would have to cover 80 percent of the cost of a prosthetic device. Ten states already have such laws.

A lobbyist for America’s Health Insurance Plans, an industry group, told the AP mandating coverage would raise premiums and “price employers out of the market altogether.”

Paddy Rossbach, president of the Amputee Coalition of America, said studies from six of the states with such laws show that covering prosthetics added 12 cents to 25 cents to monthly premiums, on average.

The benefits are worth far more than pennies a month. These devices help people maintain independence and mobility, which helps them remain healthy. Immobility, Rossbach said, can lead to obesity, diabetes, depression and other chronic conditions that, over time, can become expensive to treat.

Prosthetic limbs are not a luxury. They are as necessary to good health and a productive life as cancer treatment or heart surgery, and insurers should cover them as they would any other medical need.