Exoskeletons: How wearable robotics could transform medical claims

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  • RSA is among the first insurers in the UK to fund the use of exoskeletons
  • Claimant get back to work and become self-dependant again much faster, reducing total care costs by as much as 50%
  • Costing this technology is one of the major challengers for insurers

It sounds like science fiction, but exoskeletons are increasingly being used in rehabilitation therapy and insurers are getting in on the act.

RSA is one of the first UK insurers to look into the practical use of exoskeletons in rehabilitation for long-term disability claimants.

Carolyn MacKenzie, complex claims and strategy director at RSA, said there was a decision for insurers to make in terms of cost of the technology, versus savings from reduced care requirements down the road.

“The key to understanding these complex claims for insurers is understanding the costs,” MacKenzie said. She added the addition of exoskeleton technology could add £430,000 to a claim but could help the claimant get back to work and become self-dependant again much faster. 

Mackenzie added that Exoskeletons have the potential to reduce total care costs by as much as 50% in the future if the technology advances.

RSA currently has two claimants trialling the exoskeleton technology as an aid for rehabilitation.

The first trial claimant is a 50-year-old and diagnosed a T7 paraplegic. A T7 paraplegic will often experience total lack of function in the legs and/or torso, lack of dexterity in the fingers and hands, an inability to control the abdominal muscles and lack of bowel and bladder function.

The current settlement on a lump-sum basis was approximately £3.5m, including the cost of a Parker Indego exoskeleton until the age 70, costing around £430,000.

In this instance the cost of technology was offset by the fact that it makes a return to work more likely.

Despite this, MacKenzie makes it clear exoskeletons are not suitable for all patients. “It is not the insurer that decides this; the treating hospital will work with the injured to see if they are suitable for the technologies,” MacKenzie said.

“Learning to use these technologies takes time and extensive input from specialists such as physiotherapists.”

Collaborative approach
As a result of the specialist nature of this technology and the input of various specialists, a collaborative approach is needed in order for the insurer to fully understand the claimant’s suitability for an exoskeleton.

“Due to this collaborative approach, we will usually know that a claimant is trialling the technology and whether it is working for them,” added Mackenzie.

“At this point we will have a reasonable idea whether it will be pleaded as part of the future loss claim.”

MacKenzie added it is important for insurers to consider whether the technology is being provided to a claimant who can and will be able to use it effectively.

“The key is to work closely with the claimant solicitor to try and understand the claimant’s needs, to ensure that the requirement for technology is reasonable, that it is right for them and is going to be utilised,” she said.

“It is also important to understand what improvements such technology can bring to the claimant’s life and levels of independence.”

Advances in bio-mechatronics and medical care have made exoskeleton technology an increasingly common feature in rehabilitation programmes for those recovering from serious injury and in some cases even helping patients who have lost the use of their legs to walk again.

Dr Ravi Vaidyanathan, a senior lecturer in bio-mechatronics in the department of mechanical engineering at Imperial College London, said that the field is growing so fast at present that even defining this technology can be complicated.

"In the broadest terms, what we are talking about is a wearable robotics system used for the purpose of augmentation and rehabilitation," said Vaidyanathan.

These wearable robotics are designed to provide power for assisted movement. This power is produced using compressed air, a spring mechanism or electrical motor, which is built into the system.

The concept is relatively simple. The power sources are aligned with a patient’s joints and then can take over the role of the joint to assist movement.

“The first and least complex use for this technology is rehabilitation,” added Vaidyanathan.

“This involves working with a patient to build strength and movement after an injury – in this case the exoskeleton acts as an aid to recovery, it forms part of a much larger rehabilitative regime.”

The second medical use of this technology is augmentation. Here the exoskeleton takes on the role of the physical body, with robotics and motors taking on the role of joints and limbs for the user. This would include the building in of movement for a paralysed patient.

“On the medical side, we have seen great gains in this area,” said Vaidyanathan.

“Exoskeleton research has shown us that the technology is highly beneficial for a patient post-stroke, who is working to build strength and movement in certain fully or partially paralysed limbs.

“Where we see patients with weakness in their lower extremities then there is clinical evidence to suggest that the use of exoskeletons can help joints to work better and heal faster. In hospitals we are reasonably close to this technology becoming a reality in the mainstream.”

Vaidyanathan stressed that so far the medical applications of exoskeleton technology have been in the confined, closed and clinical environment of research facilities, hospital wards and rehabiliation centers. The systems have proven too heavy and lacking enough power for outside, unsupervised use.

In a push to make medical exoskeletons commercially available outside of the research environment, private companies and start-ups have begun to pursue wearable robotics.

Pioneers of this technology include Re Walk Robotics, an Israeli company whose Re Walk exoskeleton is already being used in rehabilitation centres in the UK.

Report confirmation
A recent report published in Medical Devices: Evidence and Research, found 76% of patients using a number of powered exoskeleton systems were able to move, without any physical assistance from another human being, following completion of a training program.

The report examined 14 studies representing 111 patients and focused on ambulatory performance, physiological demand, health benefits and safety from a number of powered exoskeleton systems.

The report’s authors concluded that a powered exoskeleton system would allow spinal cord injury patients a safe means of movement, conducive to prolonged use.

Notably, the analysis did not identify any serious adverse effects from exoskeleton use, and reports a low incidence rate of tethered falls and fractures.

Larry Jasinski, CEO of Re Walk, said the report acts as confirmation as to the multiple benefits of powered exoskeletons and will serve to boost current investment in the wearable robotics sector.

The Re Walk made headlines across the Atlantic in February last year after an insurance company in the US was ordered to cover the $69,500 (£56,527) cost of a its exoskeleton.

An independent medical review organisation overturned the insurers initial denial of coverage ruling that the exoskeleton was medically necessary for the beneficiary.

The beneficiary in question was a surgeon with a spinal cord injury and was using a custom wheelchair 11 hours a day at work. It was determined that through the use of an exoskeleton the beneficiary will be able to stand and move both at work and at home.

“The ruling by the independent medical organisation marks an important moment for exoskeletons being accepted as protocol technology for those with spinal cord injury,” said Jasinski.

“Health benefit providers have historically been hesitant to acknowledge the clinical benefits in their case assessments. This ruling, and subsequent coverage and reimbursement will help Re Walk in our efforts to facilitate greater patient access to the device.”

Industry movers and shakers

  • Re Walk
  • Ekso Bionics
  • Bionik Laboratories
  • Honda
  • Lockheed Martin


Limited availabilty
While the health benefits are well documented, Vaidyanathan stressed that this technology is very much in its infancy when it comes to availability on the open market.

“Current availability of this technology shows that there are very real issues particularly concerning a power source, battery life, system movement, comfort and financial cost,” said Vaidyanathan.

Exoskeletons are notoriously uncomfortable to wear for long periods of time due to their weight and the one-size-fits-all structure of the suits.

Current suits also aren’t designed to cope with temperature changes or rain, which makes them difficult to use in the real world.

“It is the research community that is leading the way in the development of exoskeleton technology,” said Vaidyanathan. “The trouble is that it becomes very expensive paying for all of the research – it pushes the costs sky high.”

The cost of this technology is a crucial point of contestation for insurers. The Re Walk exoskeleton has an opening cost of $70,000 with Vaidyanathan hinting that initial costs for these systems can range from $30,000 into the hundreds of thousands of dollars.

It is clear then that if a medical injury claimant asked an insurer to cover the cost of an exoskeleton, the initial pay out could be vast, and that's before medical bills, care costs and rehabilitation programs are factored in.

In recent years investment in this technology has grown. Technology market tracker ABI Research estimates that by 2025 the global robotic exoskeleton sector will value $1.8bn, up from $68m.

As investment increases and more robotic exoskeletons become commercially available, the price of the technology is expected to fall.

“Following years of ongoing research and development, a commercial exoskeleton market has finally fully emerged, though it is still in its nascency,” said Dan Kara, research director at ABI Research.

“Technological advances, now make it possible to develop commercially viable exoskeleton systems for a wide variety of applications and markets.”

Carole Chantler, a former director of clinical services at DWF and member of the Forum of Insurance Lawyers rehabilitation sector focus team, works in the field and says that costing this technology is one of the major challengers for insurers.

“Part of what insurers have got to get their head around is cost; it takes serious money,” said Chantler.

“An exoskeleton is not a quick fix. Once you remove the tools the patient is still disabled. This means that a patient will continue to require level access accommodation, they will still need care and they will still require help for the rest of their lives.”

Chantler said that alongside the initial cost there are other issues that need ironing out. “We’re dealing with robotics and these mechanical devices go wrong. Power supplies can fail, parts can break or wear out even with minimal use. These costs will need to be picked up by the insurer,” added Chantler.

A partially paralysed patient may require five or more years of rehabilitation before they are ready to use an exoskeleton. Even once the patient has access to the technology, it is common place that they may only be able to use it five or six times a year.

“The life cycle of this technology is only as long as the manufacturer’s warranty. This means that insurers will have to pay repeatedly no matter how often the technology is used,” said Chantler.

A case-by-case approach
Just as in the medical side, insurers should adopt a case-by-case approach, when evaluating a claimant’s suitability for the technology, according to Chantler.

Insurers will need to understand the patient’s motivations for requiring this technology, what effect on quality of life and care it will have and to ensure that the patient is at the right stage of rehabilitation physically and mentally.

“When it comes to a claim insurers will fight the claimant on the need for paying out the cost but only because it’s another piece of rehabilitation equipment, required by only a select few patients.”

“This is absolutely not a one-size-fits-all option for care. At the moment, this is highly bespoke technology,” Chantler added. “Cost is key for the insurer; this isn’t cheap technology.

“If there was no doubt that the individual asking for the technology would use and benefit from it then there wouldn’t be an issue. If it’s going to be used then the cost is more than reasonable.”

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60 Seconds With... Foil’s Pete Allchorne

Pete Allchorne, partner at DAC Beachcroft and president of the Forum of Insurance Lawyers, would like to be “Doctorin’ the Tardis”, finds ironing therapeutic, and can be found dancing to “Uptown Funk” by Mark Ronson and Bruno Mars.

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