Amputation Injury Claim: Prosthetics and Lifetime Costs

The hospital bills for a traumatic amputation, the surgery, the revisions that often follow, the inpatient rehabilitation, are large, and they are the smallest part of the claim. The lifetime cost begins with the prosthesis. A basic prosthetic leg costs thousands; a microprocessor knee or a myoelectric arm costs tens of thousands; an active person may need more than one device for different activities. Each lasts three to five years with daily use and is then replaced, and between replacements there are socket refittings as the residual limb changes, liner and component replacements, and repairs. Over forty years, the devices alone run into the hundreds of thousands of dollars.

Around the devices are the services: prosthetist visits, physical and occupational therapy with each new device, gait training, and the treatment of the residual limb, which is prone to skin breakdown, neuromas and pain. Phantom limb pain affects most amputees and requires ongoing management. Over time, the altered mechanics of walking with a prosthesis produce back, hip and knee problems in the remaining joints, and lower-limb amputees have elevated cardiovascular risk from reduced mobility. A life care plan projects all of it.

Then the person's life: home modifications for accessibility, a vehicle with hand controls or modifications, attendant care in some cases, and the loss of the occupation for anyone whose work was physical. A roofer, a nurse, a warehouse worker or a mechanic who loses a leg has lost the job, and the lost earning capacity to retirement, calculated by a vocational expert and an economist, is often the largest single figure in the claim.

The medical record establishes the injury: the mechanism, the level of amputation, the surgeries and revisions, the rehabilitation course and the current status. The treating surgeon and physiatrist address prognosis, the expected secondary conditions, and the person's functional capacity. A prosthetist, who fits and maintains the devices, provides the projection of prosthetic needs over life: which devices, at what cost, replaced how often, with what components and services between, and how the needs will change with age.

The life care planner combines the medical and prosthetic projections with therapy, medication, equipment, home and vehicle modification, attendant care where needed, and the treatment of expected complications, into an itemized lifetime plan with costs, which an economist reduces to present value. The vocational expert and economist calculate lost earning capacity. The defense retains its own prosthetist, planner and economist, and the differences, usually over device sophistication, replacement frequency and life expectancy, are litigated.

The loss of the limb itself is compensated as non-economic damages: disfigurement, loss of enjoyment of life, pain and suffering, and the psychological effect, which commonly includes depression and body image disturbance treated by a psychologist or psychiatrist. Photographs, the person's own account and the accounts of family describe it. In states that cap non-economic damages, amputation usually falls within the catastrophic injury exception, and the argument is made expressly.

Suppose you were 34 and riding a motorcycle when a car turned left across your path, crushing your lower leg against the car's bumper. After two attempts at salvage, your leg was amputated below the knee. You spent five weeks in hospital and rehabilitation and were fitted with your first prosthesis four months after the crash. You had worked as an electrician.

Medical bills through the first year were $312,000, paid by your health insurer, which holds a lien and which capped prosthetic coverage at a basic device. Your prosthetist's projection called for a microprocessor-controlled prosthesis for daily use and a second device for activity, replaced every four years to age 78, with refittings and components between, at a lifetime cost well into six figures. The life care plan added therapy, residual limb care, phantom pain management, the expected joint and back treatment, and home and vehicle modification. The vocational expert concluded you could not return to electrical work and projected sedentary employment at a fraction of your earnings; the economist calculated the lost earning capacity to retirement.

The car's driver carried a $100,000 policy, paid at once. Your underinsured motorist coverage paid its limit. The driver had been on a work errand, and her employer's commercial policy was the principal source, with the claim litigated and resolved at mediation after expert depositions, structured to fund prosthetic replacements for life. All figures are hypothetical; the structure is typical of a serious amputation claim.

The injured person is in hospital for weeks; a family member handles the first steps, which decide what the claim can recover.

• Identify every source of coverage in the first week: the at-fault party's policy and any excess, every household auto policy for underinsured coverage, an employer if the at-fault driver was working, a manufacturer if equipment or a vehicle component failed, a property owner or contractor for a workplace or premises injury.
• Preserve the vehicles, equipment or machinery involved; a product claim depends on examining them.
• Keep every record from the hospital and rehabilitation, and the prosthetist's records from the first fitting.
• Ask the health insurer in writing what prosthetic coverage it provides and at what level; the gap between coverage and need is part of the claim.
• Keep a record of the daily effects: the residual limb, the pain, what the person can and cannot do, and what the family does for them.
• Do not accept any offer or sign any release; the lifetime cost cannot be projected until the prosthetic course is established.
• Retain an attorney who handles catastrophic injury early; the expert work takes a year and the evidence is lost in weeks.

Damage caps on non-economic damages, where they exist, usually have exceptions for catastrophic injury that amputation meets, often expressly: several state statutes name loss of a limb in the exception. Where the cap applies to the claim category, the argument for the exception is made from the statute's wording. Government entity caps, which apply to road design and public vehicle claims, are low and rarely have exceptions.

Workers' compensation pays scheduled benefits for the loss of a limb, fixed amounts by body part that are far below civil damages and that bar a lawsuit against the employer; an amputation at work therefore turns on whether a third party, a machine manufacturer, a contractor, a property owner, a driver, is responsible, because the third-party claim is where lifetime damages are recovered. Several states have strict liability or specific statutes for construction site injuries that strengthen those claims.

In no-fault states, amputation plainly meets the threshold. Michigan's PIP, at the level selected on the policy, can fund lifetime prosthetic care and is the first question in a Michigan claim. Deadlines run from the injury, one year in Tennessee and Kentucky, two in Texas, California, Florida and Georgia, three in New York and North Carolina; product claims follow the product liability period and statute of repose; medical malpractice amputations, from delayed diagnosis of infection or vascular compromise, follow the malpractice rules with their pre-suit requirements.

Health insurance, including many employer plans and Medicare, limits prosthetic coverage: to a basic device, to one device per period, to a dollar cap, or to 'medically necessary' components that exclude microprocessor knees and activity-specific devices. The devices a prosthetist recommends for a young, active amputee are often not what the health plan will pay for, and the difference, over a lifetime of replacements, is substantial. Several states have passed prosthetic parity laws requiring coverage comparable to Medicare's, and a few require coverage of activity-specific devices, but the gap persists in most plans.

The civil claim is the source for the devices the person actually needs. The life care plan projects the recommended devices at full cost, and the health plan's limits are evidence of why the claim must fund them rather than a reason to reduce it. The health insurer's lien for what it did pay is resolved from the settlement.

A structured settlement that pays a sum every few years timed to prosthetic replacement, alongside a lump sum for immediate needs, is the common way an amputation settlement is arranged, so that the replacements are funded for life regardless of how the lump sum is managed. A special needs trust is used where public benefits must be preserved.

An amputation claim is a lifetime claim proven by a prosthetist, a life care planner and economists, against every available source of coverage, prepared for trial because insurers do not pay lifetime projections without testing them. The questions to answer early are who all the responsible parties and policies are, whether the evidence has been preserved, what the health plan's prosthetic limits are, and when the lifetime projection can be made. Catastrophic injury cases are handled by attorneys with experience trying them, on contingency.

Ask Legal Matters is a free claim-review request service, not a law firm. Requests may be shared with independent attorneys and legal services partners who handle inquiries in your state, and an attorney must evaluate the facts before anyone can say what the claim is worth. If you or a family member lost a limb because of someone else's negligence, you can request a free claim review.

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