1. Patients launch a $1.27 million crowdfunding campaign for ME/CFS gut microbiome study.
    Check out the website, Facebook and Twitter. Join in donate and spread the word!
The Fable known as The PACE Trial
Graham, Janelle and Bob, have once again excelled themselves with their latest take on the 'poisoned apple' that was the PACE Trial...
Discuss the article on the Forums.

Lost LTD Insurance appeal

Discussion in 'Finances, Work, and Disability' started by Nielk, Apr 7, 2010.

  1. Nielk

    Nielk

    Messages:
    5,088
    Likes:
    4,646
    Queens, NY
    I thought I had such a strong case. I'm receiving SSD, and my private LTD Insurance had been paying me for the past 5 years. They abruptly stopped payments after reviewing my file based on the fact that it is a self reported disability with no proof. I've been fighting an appeal for the past 2 months. My doctor who specializes in CFS wrote a great letter telling them how incapacitated I am. But, they had my file reviewed again by an "Independant Consultant" who is a rheumatologist. She claims that since I have no swelling or redness on my body, I am not sick.

    So they declined me.

    I wonder what would happen if (theoratically) I would start working full time at my previous job which they claim I can do with no problem, (I'm in bed most of the time with intermitant good days where I can go for a short walk) and I would surely regress to a much worse state, would they take the liability of my condition worsening?

    How could they since they don't think I am sick to begin with.

    I'm sorry for sounding so cinical, but I need some venting!
  2. Kati

    Kati Patient in training

    Messages:
    1,823
    Likes:
    883
    So sorry Nielk, this is not right at all. Is there possibility of another appeal, second opinion, etc???
  3. Nielk

    Nielk

    Messages:
    5,088
    Likes:
    4,646
    Queens, NY
    Thanks for your empathy.
    Yes, I am going to search for a lawyer to represent me for arbitration in front of a judge.
    But, this means paying out money and I don't know what the outcome will be.
    I need to fight this though even if it just for the principle of trying to prove how unfair these insurance companies are.
  4. paddygirl

    paddygirl Senior Member

    Messages:
    163
    Likes:
    20
    Hi Nielk, hopefully we won't have to put up with this situation for much longer. Have a look at masscfids.org, they have an excellent disability and employment section. Best of luck to you.
  5. Nielk

    Nielk

    Messages:
    5,088
    Likes:
    4,646
    Queens, NY
    Thanks Paddygirl!
  6. Esther12

    Esther12 Senior Member

    Messages:
    5,107
    Likes:
    4,908
    Sorry to hear this Nielk.

    It's quite likely they turned you down as a matter of course, in the hope you'll just accept it. Good luck with the appeal.
  7. alice1

    alice1 Senior Member

    Messages:
    457
    Likes:
    0
    Toronto
    So sorry about this Nielk.
    Hopefully you'll get someone who knows how to handle them.
    Good Luck!!
  8. Nielk

    Nielk

    Messages:
    5,088
    Likes:
    4,646
    Queens, NY
    Thank you so much!
  9. Nielk

    Nielk

    Messages:
    5,088
    Likes:
    4,646
    Queens, NY
    Thanks for your concern!
  10. dsdmom

    dsdmom Senior Member

    Messages:
    390
    Likes:
    45
    Sorry about this - I am in the middle of an appeal. Talk to a few lawyers and see if you can find one who will take your case on a contingency basis. You'll pay a portion of whatever you get in back payments but you won't be out any $ up front.
  11. Nielk

    Nielk

    Messages:
    5,088
    Likes:
    4,646
    Queens, NY
    Are you appealing with a lawyer?
    I did it by myself so now I have no choice but hire an attorney.
    Hopefully, I'll find one to take me on contingency.

    Good luck with your appeal!!!!
  12. dsdmom

    dsdmom Senior Member

    Messages:
    390
    Likes:
    45
    I did my first appeal by myself. And thought it was pretty good! But now that I have an attorney I've learned that it really doesn't matter how good it is...most companies (and the one I'm dealing with in particular) say no no matter what. It's disgusting that there really are no laws governing the fairness of their decisions. Anyway, yes, I did get an attorney and we are almost done and will submit our appeal soon. My attorney has told me to expect that the disability company will probably say no again (this one is notorious for it). And then we'll go into litigation and they will probably just want to settle at that point.

    Now it may be different with whatever company you are dealing with but definitely get an attorney. I called/interviewed a few of them before I settled on one. Make sure you meet with them before you commit anything to make sure you are comfortable with them and they are competent. Good luck!
  13. Nielk

    Nielk

    Messages:
    5,088
    Likes:
    4,646
    Queens, NY
    Thanks a lot for the good advice.
  14. Lynn

    Lynn Senior Member

    Messages:
    301
    Likes:
    50
    Hello Nielk,

    There are many good lawyers that handle LTD disputes for PWC's. I think it is important to get someone who is knowledgeable about our disease. It doesn't matter whether the attormey is close to where you live. I can recommend an attorney in Chicago named Mark Debofsky that got the job done for me. I have no affiliation with his company. His website is http://http://www.ddbchicago.com/

    I was turned down twice by my LTD insurer but once I received SSDI, he managed to get my LTD benefits right away. Usually the LTD benefits require a lower standard of proof thean SSDI. If you have SSDI then a competent attorney should be able to get you the LTD benefits.

    I hope that helps.

    Lynn
  15. caledonia

    caledonia

    Messages:
    2,698
    Likes:
    1,293
    Cincinnati, OH, USA
    You should not handle the appeal yourself! You should get an ERISA disability lawyer to handle the appeal. The reason is that once you run out of internal appeals, you'll have to sue them in Federal Court. Once you run out of of internal appeals, you can no longer add evidence (medical or legal) to your file. So you need a lawyer in there right away, making sure your file has all the right info in it.

    I only had one appeal. Hopefully you'll have more than one.

    Sorry, but getting approved for SSDI means nothing to the LTD's. They'll just claim that their standards are different from SSDI.

    The advice for finding a lawyer is good advice. Pick three to interview (will cost you $100 or so), then go with the one you like the best. You may not be able to find one familiar with CFS per se. Mine was familiar with FM though and that was enough to make me feel comfortable. But really, they don't argue that you have this or that illness or not, they argue that the LTD violated their contract with you and are operating in bad faith. So even if they're not familiar with CFS, it's not that big of a deal.

    You may have to pay out of pocket for the appeal, then once you have to sue them it can go on contingency.

    When you add up all the years of payments that you can lose if you don't have a lawyer, $1500 or whatever it costs out of pocket is well worth it. Even if you end up with a settlement, it will still be worth it.
  16. BEG

    BEG Senior Member

    Messages:
    941
    Likes:
    162
    Southeast US
    Good luck to you, Nielk. I hope everything works out for you. My friend, also with RA and CFS, is always having her LTD insurance review her. She personally gets her doctor's notes and will have something changed if she doesn't like it.
  17. Nielk

    Nielk

    Messages:
    5,088
    Likes:
    4,646
    Queens, NY
    Thank you everyone for your advice and concern.
    I'm busy finding a lawyer in NY.
    I'll keep you guys posted as to what happens.
    I agree that it's definitely worth the money to fight because when you figure the total
    sum for the next 20 years, it amounts to a big sum.
    Although, hopefully I'll recover before that and not need them.
  18. calzy

    calzy Senior Member

    Messages:
    113
    Likes:
    0
    Naples Florida
    Unum?

    If your company is UNUM:eek: dont mess around without an attorney:eek: I went thru hell trying to get my LTD, after 5 years finally got it. One of the reasons they gave in is because I had not worked for all that time:confused::headache::sleepy::In bed:


    GET An ATTORNEY!
  19. shiso

    shiso Senior Member

    Messages:
    159
    Likes:
    6
    Calzy - I am in awe of your tenacity - 5 years! You are an inspiration. Congratulations on your well-deserved win. :victory:
  20. calzy

    calzy Senior Member

    Messages:
    113
    Likes:
    0
    Naples Florida

    haha..thank you...I never gave up but lost all of my retirement $ in the meantime.

See more popular forum discussions.

Share This Page