‘One limb per lifetime’ insurance policy leaves Devils Lake man fighting for change

“Nobody should be treated that way. To me, it’s medical neglect.”
Updated: Jun. 14, 2021 at 6:48 PM CDT
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DEVILS LAKE, N.D. (Valley News Live) - A Devils Lake family is calling for change tonight for amputees in North Dakota as their insurance company recently denied a claim, stating its policy only covered one prosthetic limb per lifetime despite doctors saying that’s the opposite of what’s medically needed.

Every morning Jason Hunter layers on on a total of 32-ply socks in order to make his current prosthetic leg kind of fit, which is a move doctors say is dangerous, but for right now, that’s the only option he has.

Hunter prosthetic denial letter
Hunter prosthetic denial letter(KVLY)

“Honestly it’s ridiculous. I mean, nobody’s body has stayed the same as when they were 19-years-old as far as I know,” Hunter said. Hunter’s insurance policy reads: “Prosthetic limbs, sockets and supplies, and prosthetic eyes limited to one (1) per lifetime unless medically necessary due to growth for Members under 19.”

Hunter was hit by a car on his motorcycle in May 2010, when a 94-year-old woman crossed the centerline and hit both Hunter, as well as a man and his pregnant wife, killing her.

“It was the blink of an eye,” Hunter said.

Jason says exactly three months later he was walking on his new prosthetic leg, and he says since then he’s had at least 20 different sockets. While that number may seem high, Altru Health Prosthetist Paul Edman says it’s completely normal and to be expected.

“There just isn’t that much margin for error with a prosthetic limb that you can reasonably expect one to last a whole lifetime. When you get a poor-fitting socket, you’re going to get a skin break down, an ulcer and potentially an infection, and a revision surgery and a hospitalization,” Edman said.

Edman says he’s only seen an insurance policy like Hunter’s one other time in his career, about 10 or 15 years ago.

“When you’re walking all day long on something that doesn’t fit, and we know we’re going to have problems if we don’t take care of it, it’s unethical to not take care of it,” he said. “If you’re strictly looking at the cost of care, it’s much cheaper to have them in a well-fitting prosthesis than to have them in a hospital bed.”

As a state employee for the Department of Transportation, Hunter’s coverage comes from Sanford Health, but the policies come from NDPERS, The North Dakota Public Employees Retirement System.

The Hunters say they were told the policy on prosthetics changed in 2017, but say they were never notified or impacted until late this April.

“He got limbs in 2017, 2018 and 2020, yet this one was denied,” Amber Hunter, Jason’s wife said.

This, despite the following conditions listed underneath the policy: “Adjustments and/or modification to the prosthesis required by wear/tear, due to a change in member’s condition, or to improve its function are eligible for coverage and do not require preauthorization or prior approval.”

“I would assume that’s exactly what my husband is trying to obtain,” Amber said.

NDPERS policy

For now, Jason is still in the dark as both Sanford Health and NDPERS have stated they are reviewing his case. The delay in action leaves Hunter trying to push through the pain and sores developed from his now ill-fitting socket. He says he hopes the issue is resolved before he is forced to be wheelchair bound full-time.

“There needs to be change and it shouldn’t have to wait,” Amber said.

Only 21 states have insurance laws that protect amputees, but North Dakota and Minnesota aren’t one of them which is something both the Hunters and Edman say needs to be fixed.

“If you ever have a loved one lose a limb, it does change you more than you can imagine. So, I will fight and if it doesn’t change now, I’ll be there when legislation starts,” Amber said.

Valley News Live reached out to NDPERS President Scott Miller today to ask if a change in the policy can be expected anytime soon. In a statement Miller wrote:

“The language regarding coverage for prosthetics is not a North Dakota Public Employees Retirement System (NDPERS) “policy”, as that word is used by state agencies. Instead, that language is part of the broad array of covered services addressed by the Certificate of Insurance (COI) that governs the health plan offered by NDPERS through Sanford Health Plan (SHP). The NDPERS Board of Trustees includes as many covered services within that COI as it can for the premium that is approved by the North Dakota Legislative Assembly.

The Board considers potential changes to the health plan on an ongoing basis. If a change would result in no or minimal premium change, the Board has the statutory authority to make that change, and pay for it out of health insurance reserves if there is a minimal cost. However, if those changes would result in a significant premium increase for our state agency and political subdivision employers, those changes would need to go through the legislative process.

The health plan’s coverage of prosthetic devices has been one of the topics of recent discussion. The Board and I and my staff have been working with SHP to evaluate the breadth of our current benefit plan and the potential cost if we were to expand that coverage. Those discussions have not yet concluded. As a result, I do not yet have an answer to your question.”

The Hunters have been offered to have Jason’s next prosthetic be half the price, but at over $6,400 the community has put together a benefit for the family this Wednesday night in Devils Lake. The event goes from 4:30 p.m. to 7:30 p.m. at KC Hall at 522 4th St.

There is also a donation account at Western State Bank under ‘Hunter Benefit.’

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