For 12-Year-Old Without an Arm, Insurance Has Run Out

Benjamin French was born with his right arm missing below the elbow. In his 12 years, he has been fitted with seven prostheses. His most recent replacement will cost nearly $30,000 and his doctor says he will soon grow out of it.

But, according to his insurance company, the boy is ineligible for further coverage of prosthetic devices because he has already spent his lifetime maximum benefit.

Benjamin’s family happens to live in Michigan, one of 33 states where insurance companies are allowed to set annual and lifetime caps on prosthetic coverage. The family’s policy with Blue Cross Blue Shield of Michigan covers a maximum of $30,000 per lifetime for prosthetics, plus $1,000 per year for repairs. In states such as Colorado and Maryland, the law says there can be no such cap on prosthetics.

“It seems really unfair,” said Benjamin’s mother, Kristen French. “The insurance company can do this in one state, but not in another? It’s ridiculous.”

The French family represents one small part of a for-profit health care system rife with inequities and inconsistencies: Some people have insurance, some do not. For those who are insured, individual policies operate under different rules than group policies. Each insurance company and every individual policy has different requirements, exclusions, and benefits.

And, as in the case of Benjamin French -- people with nearly identical health problems may have vastly different experiences with their private health insurance companies depending on their state of residence.  Another example of the inequity: If Benjamin’s family were poor enough to qualify for Medicaid, most if not all of the cost of his new arm would be covered.

The French’s case emerged from the Huffington Post Investigative Fund’s citizen journalism project, which is calling on readers to help provide information, data and anecdotes about the inner workings of the insurance industry. One common theme among the responses is the wide variation in state rules.

States hold the primary regulatory authority over health insurance and each has different laws governing which benefits must be offered to its residents. Some of the state rules deal with major health issues and sometimes – as happened with treatment for mental illness – they have prompted insurers to expand coverage nationwide. Some states have adopted mandates for more specialized coverage, including the removal of birthmarks and varicose veins. Arkansas, Georgia and Vermont even require insurers to pay for personal trainers for people who need to lose weight for health reasons.

When a state lacks a mandate for a specific benefit, that doesn’t necessarily mean insurance companies won’t cover it anyway. For example, a handful of states do not require insurers to provide coverage for chemotherapy or treatment for Alzheimer’s disease – though that coverage is common in many insurance plans. Fourteen states do not require insurers to cover prostate cancer screening, though many plans may offer the benefit anyway.  

Prosthetics is one area where the lack of a mandate seems to cause problems for many patients.

Within this decade, 17 states have passed laws requiring that insurers pay for prosthetics on par with federal programs such as Medicaid, but in the other 33 states, insurers do not have to offer coverage for prosthetic devices and also can set annual or lifetime caps on coverage. These caps on prosthetics are similar to the caps on mental health coverage that were recently made illegal by a federal mental-health parity law, scheduled to go into effect in January.

“These rules are illogical and arbitrary,” said Kimberly Hoyt, a specialist in Denver, Colo., who designs and fits prosthetic limbs. “You have to be an investigative reporter to figure out which states have parity laws and which states don’t.” Since Colorado became the first state to pass prosthetic parity legislation in 2001, Hoyt said, she has seen fewer denials overall for prosthetic limbs, but gets frustrated when she sees patients, such as college students, who cannot get coverage because they are insured in states with looser rules.