My disability company drives me crazy! Need advice.

[caledonia]

I did a 2 day test, then documented via my doctor that I was crashed for a week or two afterwards. In retrospect, either a one or two day test would have been sufficient in my case. My heart rate would zoom up to unsafe levels after very small exertions. The lady administering the test was looking very concerned.

 

[caledonia]

Sued as a part of the ERISA appeal or separately later, I wonder?

They would never tell me what sort of testing they were looking for. Just told me that everything I provided was insufficient to prove disability. .

Of course, it's been 2.5 years now since I lost the appeal. I'm sure it's too late to sue them now. But it is tough to get over.

ERISA is tricky - done that way on purpose as it was written by insurance lobbyists. When you do the appeal, you must have a lawyer do it. The reason is you will likely lose the appeal. Then the next step is to sue them.

At this point, you can't put any more evidence into your record. So you want the lawyer handling the appeal, so they can make sure all the right evidence is your record. Then you sue them based on various breaches such as not telling you what evidence is needed to satisfy them that you're disabled.

My lawyer came up with three breaches in my case. We won the lawsuit, but they appealed it. Then it went back to the judge and he was going to slap them down again. Then they decided to settle. When it was all said and done, I ended up with about a year's salary. The whole process took five years.

I'm now wondering if the original poster had a policy outside of ERISA. In that case, the rules are different. He can sue for damages on top of just getting his disability payments. But companies don't usually deny people in that situation, as they have a lot more to lose.

 

[Iritu1021]

ERISA is tricky - done that way on purpose as it was written by insurance lobbyists. When you do the appeal, you must have a lawyer do it. The reason is you will likely lose the appeal. Then the next step is to sue them.

At this point, you can't put any more evidence into your record. So you want the lawyer handling the appeal, so they can make sure all the right evidence is your record. Then you sue them based on various breaches such as not telling you what evidence is needed to satisfy them that you're disabled.

My lawyer came up with three breaches in my case. We won the lawsuit, but they appealed it. Then it went back to the judge and he was going to slap them down again. Then they decided to settle. When it was all said and done, I ended up with about a year's salary. The whole process took five years.

I'm now wondering if the original poster had a policy outside of ERISA. In that case, the rules are different. He can sue for damages on top of just getting his disability payments. But companies don't usually deny people in that situation, as they have a lot more to lose.

Hey guys, I'm the original poster. Thanks again for sharing all your stories and useful advice. I think its inhumane that they make you do a test that makes you crash for two weeks afterwards. This simply should not be allowed!

I'm still trying to figure out if my policy is ERISA or not. There may be a glimmer of hope that it's not because I purchased it through Texas Medical Association Insurance Trust which is a state sponsored organization and apparently these seem to be often exempt from ERISA.

The lawyer I spoke to wasn't sure so he forwarded it to his colleague to find out. If that turns out to be the case, then the insurance company will be in serious trouble. I read that they are so used to being protected by ERISA that allows them to do whatever the hell they want and not worry about any consequences, that they tend to forget that once in a while there are some patients who can actually sue them and win. (The lawyer office that I'm talking to right now describe a case on their website of a CSF patient who got dropped from her coverage, she sued Prudential and won million of dollars because her case wasn't covered by ERISA.)

My disability policy is LTD but I paid extra money for 30 day waiting period rather than the customary 90-180 days because I knew I wouldn't have enough savings to make it that long. I had no idea that they can take six months just for the review!

 

[Kati]

My best wishes @Iritu1021. Going through this process is very stressful on top of dealing with life changing aspects of a potentially long term chronic illness. Fingers crossed that yours is only temporary. Do make sure you are entirely well before returning to work. A big mistake people do is they return to work too early.

 

[Gingergrrl]

Do make sure you are entirely well before returning to work. A big mistake people do is they return to work too early.

I made that mistake twice and really regret it. I would do things very differently if I could go back in time.

 

[Ecoclimber]

It's way more difficult to try to overturn a decision on appeal. It's best to attack at the lower court. Below is must read on how insurance companies obfuscate disability claims. Merrick was a hedge fund manager but what he did in attacking the insurance company was to file a civil RICO. Under this act, special discovery rules allowed the plaintiff to open this company like a can opener. It is an expensive litigation process then a normal rebuttal on appeal but the fruits were well worth the cost. However, it must be noted as a caveat that Texas courts are more conservative so the same outcome could be different in a different jurisdiction. Hope this helps somewhat.

MERRICK v. PAUL REVERE LIFE INSURANCE COMPANY

Cliff notes located here

 

[acer2000]

Yeah so in my case, they denied my application for LTD initially. Then we appealed the denial with the same undeniable objective evidence that I couldn't do my job due to illness and they claimed that the laptop with my case on it was stolen and there was no backup. My lawyer pushed them on it to produce a police report and they never did. This was clearly a stalling tactic and an effort to get me to re-submit all of my data all over again. It was also likely a HIPPA violation. Once their time ran out and they hadn't rendered a decision, we threatened suit against them in federal court and they then approved me. I later learned from someone else that this same insurance company had used the "stolen" laptop delay excuse before.

The irony is, because this is an ERISA case they don't even pay me that much money. SSDI pays at least half of their liability.

Every couple years since then, I have to "re-prove" to them I am still sick at great expense. Their game is to try to run up the doctors bills and legal fees on your end so you will give up.

I was 25 years old when I first got sick and had to deal with this. Had I not had my parents step in and help me financially, I probably would have been on the street and/or dead. To this day I am ashamed that I had to take money from my parents. I worked hard in college and had great job/supported myself as soon as I graduated. The whole thing makes my blood boil.

I can tell you this though, after watching me go through this ordeal, every one of my friends/family opted into disability policies and/or bought private policies. The non ERISA policies are not subject to income tax because they are paid with post tax dollars (vs ERISA plans which are often paid by the employer as a benefit). Also, if you are in your twenties, its often very inexpensive to buy "upgraded" coverage through your employer's plan. In my case, my base plan covered 50% of my salary. Had I paid $4 more per paycheck, I would have had 70% coverage (tens of thousands of dollars more in my case). But hey, who thinks you will ever get sick when you are 25?

 

[Kati]

Yeah so in my case, they denied my application for LTD initially. Then we appealed the denial with the same undeniable objective evidence that I couldn't do my job due to illness and they claimed that the laptop with my case on it was stolen and there was no backup. My lawyer pushed them on it to produce a police report and they never did. This was clearly a stalling tactic and an effort to get me to re-submit all of my data all over again. It was also likely a HIPPA violation. Once their time ran out and they hadn't rendered a decision, we threatened suit against them in federal court and they then approved me. I later learned from someone else that this same insurance company had used the "stolen" laptop delay excuse before.

The irony is, because this is an ERISA case they don't even pay me that much money. SSDI pays at least half of their liability.

Every couple years since then, I have to "re-prove" to them I am still sick at great expense. Their game is to try ti run up the doctors bills and legal fees on your end so you will give up. I was 25 years old when I first got sick and had to deal with this. Had I not had my parents step in and help me financially, I probably would have been on the street and/or dead. The whole thing makes my blood boil.

@acer2000 I gave you a like because I think it's important for people to never give up. We have paid into insurance and we are sick. It can be incredibly tough but do not give up.

And really, insurance companies have much to loose if the customer is young like you or had a paying job. So they fight harder. Make sure you do everything right, see the right people, get the right reports. Do not give up.

 

[acer2000]

@acer2000 I gave you a like because I think it's important for people to never give up. We have paid into insurance and we are sick. It can be incredibly tough but do not give up.

And really, insurance companies have much to loose if the customer is young like you or had a paying job. So they fight harder. Make sure you do everything right, see the right people, get the right reports. Do not give up.

Oh I know. Its even worse because I worked for a company where probably 90% of the employees were under 40 and in great health. Their health/disability plans are making money hand over fist.

 

[Iritu1021]

Acer2000, that's crazy that they used the "stolen laptop" excuse. I have worked for a medical company that was doing third party medical reviews. One executive had a laptop stolen from his car that had patient information on it and our company as a result was involved in a highly publicized lawsuit, they had to settle for millions of dollars for HIPPA violation. We had Draconian laws about securing our laptops with metal cables even if you just go to the bathroom because of that case. Maybe HIPPA wasn't as big back when it happened but nobody would get away with such a a lame excuse now, if anything they'd try to hide it from you so that you can't sue them. Your story makes my blood boil too!

Whatever is the outcome of my case, I still plan to write to state department of disability about their practices. I know one voice is just drop in the sea, but I feel that if we all came together and shared our stories, made them public, there would be some public outrage that would create a drive for change. Not so long ago big medical insurance companies were also doing whatever they wanted to their patients. I remember how when I was in between jobs my four month old son was denied medical coverage because of his "preexisting diagnosis" of gastric reflux at the age of two months(for some reason it was an exclusion criteria on their list, even though 1 out 2 babies this age have reflux! )

I wrote a letter to California senator Barbara Boxer about it and her office even replied saying that that's what they are fighting against. Now it's 2014 and there is a law that prevents from insurance companies from doing things like that. So I feel that if we all try to really speak up than maybe we can at least help those who come after us because this injustice cant go on forever...

 

[acer2000]

Yeah this was in 2009. I should have pursued them on a HIPPA violation.

And it's true that health insurance companies themselves are prohibited from certain "bad" practices by the ACA. However, I have noticed that very frequently they outsource the handling of claims to third party servicers or "benefits managers". These companies make lots of "mistakes" that have a similar effect to the bad practices that insurance companies themselves used to do. Delays in coverage, denial of claims, billing "errors" (always in their favor), etc.

The cynic in me says that this arrangement allows the primary insurer to avoid responsibility while saving money because their contractors use these tactics. I guess I'd have to read the ACA to find out what is prohibited and what isn't. I filed a complaint with CMS/HHS about this practice this year. I was forced off a medication that I needed for months while my plan's benefit's manager dicked around with my claim.

 

[Kati]

This disease, along with a few others are easy prey because of shady diagnostic criteria, and also the sources which say that the treatments for our illnes is cognitive behavioral therapy and graded exercise therapy. it is very, very important to see the right doctor.

 

[Gingergrrl]

Also, if you are in your twenties, its often very inexpensive to buy "upgraded" coverage through your employer's plan. In my case, my base plan covered 50% of my salary. Had I paid $4 more per paycheck, I would have had 70% coverage (tens of thousands of dollars more in my case). But hey, who thinks you will ever get sick when you are 25?

@acer2000 You make an excellent point that I cannot stress enough. When I got hired at my job I was 31 yrs old and in perfect health. I almost made the horrific decision not to buy any disability coverage b/c I thought that I did not need it. One of my then new co-workers pulled me aside and said that when you are hired, you can choose any disability plan you want, regardless of pre-existing conditions, but later on if you become sick, you never have the opportunity to purchase any plan and she was correct (for the hospital where I worked.) Even though more money came out of my check 2x/month for the more expensive plan, she talked me into it and I am now receiving 70% of my salary. I worked there full-time for 12 yrs before going out on disability and was an incredibly loyal employee. Buying that plan was one of the best decisions I've ever made. No one thinks they will get ill and I certainly didn't.

Had I not had my parents step in and help me financially, I probably would have been on the street and/or dead. To this day I am ashamed that I had to take money from my parents.

Acer, pleased do not be ashamed that you took money from your parents. It sounds like they loved you and wanted to help you and did it of their own free will. This is a brutal illness and if I had not, by the grace of God, bought that disability plan (which I literally almost did not buy) and did not have my husband, I would be living with my parents right now. If the tables were turned, I would help any member of my family if they were in my shoes. I really understand the guilt, it keeps me up at night, but we did not ask for this illness and if we were well enough to be back in the workforce tomorrow, we would jump at the chance.