Advice with Insurance Company on Short Term Work Leave

[bertie7]

I have had CFS for over 25 years and was able to manage it so that I could work full-time with a job that had a lot of flexibility with control over my time and ability to manage my illness.

I took a turn for the worse in 2012 and have since been re-tested for a variety of viruses and bacterial infections and was finally diagnosed with Bartonella ( as at least being part of the overall illness) however when I started the protocol which consists of antibiotics and enzymes I became dramatically worse (possible herxing etc) and found it was impossible to work as I have constant intestinal issues, fatigue, migranes, lymph node pain

I have applied for a short term work leave as a benefit from my company (which allows me to receive a percentage of my salary) but the insurance firm keeps telling me that my doctors office is not giving them the specific information they need in order to make a assessment of the claim. I have contacted the my doctors office (they are well known on this forum) and they said they have submitted my labs, meds and official HPPA documents etc and don't know what else to provide.

Has anyone had experience with this? Can anyone advise on what to tell the insurance company or what to tell the doctors office to tell them etc? What exactly is the insurance company looking for from the doctor. I contacted the insurance company and they said the doctor is not specifically addressing their questions such as what are the exact restrictions, limitations, etc

I was notified by the insurance company yesterday that my claim will be considered denied without this information

Does anyone have any advice or suggestions?

 

[Esther12]

Could you ask the insurance company what specific information they need, then pass this on to your doctors office?

 

[PennyIA]

Agreed. The five times my doctor put me on short term work leave he spelled out that I wouldn't be able to work for a minimum of X (which was usually three months)... and then he would extend it if I needed it from there.

He never called out I couldn't carry things or that I wouldn't be able to work in an office or anything else. Sounds like they aren't convinced you need Short term Disability even when your doctor says so.

 

[KitCat]

I have heard that these insurance companies require a lot of paperwork from doctors. It is not enough to just send medical records, there are specific forms they require the docs to fill out. That is what I have been told (I haven't done this myself).

If I were you I would contact the insurance company, ask them to send you a copy of the form they want your doctor to fill out and then make an appointment with the doctor to go in for an office visit and fill out the form.

If at all possible, I think it's important to sit with your doctor when they fill out the form and go over the questions with them. Otherwise, you have no idea what your doctor will write.

It's always best to be extremely clear with your doctor about all of your limitations. Your doctor may or may not remember all of the specifics of your case, and almost certainly won't take the time to go back through your file and carefully check. You can look over the forms yourself and think ahead of time about what all your limitations are so you can give your doctor the best information.

There is a woman named Linda Nee who has a good blog about employer disability (she is a whistleblower - used to work for one of these companies and now writes a blog advocating for disabled people). I believe she will give a free consultation.

 

[KitCat]

p.s.

It's great that you are following through and looking into this. that is exactly what you need to do! It is great that you are making phone calls and asking questions and looking into it. well done!

From what I have heard from other people on LTD and STD, you need to have a doctor who is supportive of your disability application and willing to fill out disability paperwork. If your doc is very firm and consistent in their support... very clear that you are completely unable to work and clear on your limitations and that you are severely impaired, and then you can get approved. That's what I have been told.

It doesn't matter what your doc says to you, or what their office says to you, all that matters is what they write down.

If at all possible, it would be a wonderful help for you to get your records and read them all. I know many people who never collected their medical records and then several years later found out that the records were not what they had thought. Its really great to know early on.


also:
If there is any chance that you will be applying for LTD or social security, then you don't want your doctor to write that you will be better in three months, that can hurt your other claims. It is better to say recovery unknown.

 

[taniaaust1]

Sounds like your doctor isnt being specific enough for your insurance company, probably cause your doctor isnt exactly aware of all your limitions to be clear enough to put it how your insurance company want it.. just putting "he cant work" isnt enough. (and insurance companies if they can will not pay a claim)

You need to get the insurance company form with their questions and then be there while your doctor fills it out so you can give doctor required info.

 

[xrunner]

What exactly is the insurance company looking for from the doctor.

You need a letter from your GP detailing your diagnosis and the medical reasons why working PT (or not being able to work at all) is recommended for your health situation. Ideally you would also need a diagnosis and similar arguments from a consultant.
With two doctors' opinions on your side it would be very unlikely for your insurance company (and their consultants) to turn down your claim.
This is one area, at least in the UK and in my personal experience, where a diagnosis of ME/CFS with its implications on activity limitations etc. once established by physicians and independent consultants is accepted for insurance purposes more easily than alternative diagnosis such as for e.g. chronic Lyme, Bartonella or similar.

 

[KitCat]

Sounds like your doctor isnt being specific enough for your insurance company, probably cause your doctor isnt exactly aware of all your limitions to be clear enough to put it how your insurance company want it.. just putting "he cant work" isnt enough. (and insurance companies if they can will not pay a claim)

You need to get the insurance company form with their questions and then be there while your doctor fills it out so you can give doctor required info.

great advice.

I totally agree with this. It's really important to go over all your limitations with your doctor so they know exactly what you cannot do.