Long-term Disability (LTD) Appeal was denied (US)

[sleepwalking]

I found out last week that my LTD Appeal was denied. I knew that the decision was pending and that I should have an answer shortly before XMAS.

When I didn't hear anything I started emailing my attorney who I found on the Yahoo Disinissues group site. You can imagine how antsy I was. I had a high paying salary and paid into a really good LTD policy and they cut me off with no warning last April at the 2 yr mark.

They had me under video surveillance for 2 weeks and I left the house once during that time to go to the doctor, the ATM machine to deposit a check and stopped at the grocery store for some grub. They said if I was able to do those things that I could work. Then they sent the video and their interpretation of it and sent it to every doctor I've seen in the last 2 yrs asking if after viewing it if they thought I was so disabled I couldn't work. They got a bite from my podiatrist who said I may be able to do sedentary work and walla! That's all they needed to deny my claim.

The attorney said I had a really good case. I had 5 letters from doctors that said I was disabled. The last was a physical capacity evaluation completed by a Rhuematologist. I won my SSD case in June. And the video shows me limping and using a cane and never lifting any groceries.

So over the Holiday I went into an old email account that I haven't used for 6 months and there was the email from my attorney saying that my case was denied on Dec 11. I don't rate a phone call, perhaps a letter? They suddenly forgot my current email address? Here it is Jan 7 and I still have not talked to them in person. They are avoiding me like I have the plague. Today I received my case file in a large box from Fed Ex with a letter saying that they have decided not to litigate the denial because I can't afford them. The appeal they did was on contingency. If I won they would take half of my monthly payments. Since I lost, there is no incentive for them.

Because I can't work and I'm poor I guess I can't fight this.

I'm pretty down. Any suggestions?

 

[flybro]

Sorry I can't help you i'm in the UK, however I have been turned down twice for disabilty. I know what a smack in the face it is, and how hard it is to fight them.

It so hard with an up down illness, and having to prove your illness hardly aids any attempt your body makes at wellness.

Best I can offer is a bit of empathy, which I know don't pay the bills, or buy the food, but it's all I've got.

Hugs@ya

 

[sleepwalking]

Thank you. I'll take the empathy. It seems to be in short supply these days.

 

[alice1]

Don't you dare give up!
That's exactly what they want.You find another lawyer,it'll be hard but you'll do it and have you day in court.
Until then a big squeeze,.
al

 

[fresh_eyes]

Oh, sleepwalking, argh, that SUCKS. I wish I had some great advice for you...Just hang in there! And hang around here, there are lots of smart, caring, knowledgeable people on this forum.

 

[Kati]

I also vote for not giving up. Keep on trying, a day at a time, seek out health advocacy groups, disability groups, and lawyers. Keep track of your ins and outs, symptoms, etc... And never give up. Dr Klimas said herself it is not time to give up.

There should be a CFS association nearby that could perhaps offer some advice?

Big hugs, we are all here.
Kati

 

[Countrygirl]

Disgraceful treatment.

Because I can't work and I'm poor I guess I can't fight this.

I'm pretty down. Any suggestions?

Dear Sleepwalker I'm so sad and angry to hear of your predicament. I have been there a number of times over the decades and it is a disgrace to be treated like this when so unwell. The only way is to keep fighting, but to have to do that when having to cope with such a debilitating condition is inhumane.

If you were in the U.K., I could possibly get you the evidence you need to fight your case. Sadly, you are the wrong side of the pond for that.

All I can do is to send you a big hug....doesn't pay the bills I know....and my very best wishes.

Keep us posted.

C.G.

 

[alice1]

sleepwalking I agree with Kati.There has to be groups near you that can help.Maybe someone on the board can give you names and contacts.
If you want to write down your area we could start there.Hang in.

 

[dsdmom]

Out of curiosity, who was your long-term disability company? I do not believe that videotapes prove anything and a good lawyer should be able to argue that. I would suggest researching other attorneys who would also take your litigation on contingency.

It's interesting that they cut you off @ the 2-year mark. Is it possible that they classify CFS as a psychological/mental disorder? Most disability companies have a 24-month clause in there that they will only cover mental disorders for 24-months.

 

[Robin]

Out of curiosity, who was your long-term disability company? I do not believe that videotapes prove anything and a good lawyer should be able to argue that. I would suggest researching other attorneys who would also take your litigation on contingency.

I wish I could help you, too! I'm so sorry that this happened.

I think you have a case for appeal -- it's weak that the insurance company thought a podiatrist is qualified to make a disability judgment (unless it has to do with your feet), and going out once in two weeks is another point of argument.

I would just start calling law firms; someone might want that contingency!

 

[Dr. Yes]

Hi sleepwalking,

I have a pretty good feeling for what you're going through.
:Sign Help:

Too bad I have zero feeling for legal matters. Just wondering in ignorance.. is unauthorized surveillance by an insurance company admissible court evidence, let alone legal?? Sounds like something the ACLU should be suing about...

There are quite a few members here from the Bay Area (some have it noted in their posts, under their avatar), and I wonder if any of them may know good local legal services? I'll ask a couple I know, and you can PM any one of 'em too, I'm sure; people are real friendly around here.

 

[sleepwalking]

Thanks everyone! I really needed this vote of confidence to keep up the good fight. I'm just so sick that finding the energy to fight is very hard. I think I'm on a time limit but have no idea what it is. I asked the old attorney (Kantor Law) and they only answered by telling me to find a new attorney ASAP.

The unscrupulous Insurance Company was Hartford for those who wanted to know.

 

[kit]

Hi Sleepwalking,
I am sorry your appeal got denied. It is really hard to fight when you are so sick, it's also so unjust that you should have to fight for the benefits you worked for. I agree, don't give up trying. I've talked to several attorneys who were willing to cut deals financially, though I don't live near you so I can't make a specific recommendation. But you may be able to find someone who will take it on contingency, or might want just a little bit upfront. Also, you might try asking as many people as you know personally for attorney recommendations. The attorneys that I've worked with have been friends of friends, or friends of friends of friends. It does seem to increase their willingness to take the case and go to bat for you when you have a personal connection.

 

[caledonia]

I would try and find another lawyer.

My case was a little different, because they denied me from the outset, and never paid me anything. I got a lawyer, we appealed the denial, they denied that. That was paid out of pocket. Then we went to a contingency plan. We sued them in Federal Court and won. They appealed, we appealed their appeal and just before it was ready to go to court again, we settled. They had made some lowball settlement attempts before that which we turned down.

My lawyer said that even if we lost in court, he could get $10,000 out of them in some kind of settlement.

 

[markmc20001]

I found out last week that my LTD Appeal was denied. I knew that the decision was pending and that I should have an answer shortly before XMAS.

When I didn't hear anything I started emailing my attorney who I found on the Yahoo Disinissues group site. You can imagine how antsy I was. I had a high paying salary and paid into a really good LTD policy and they cut me off with no warning last April at the 2 yr mark.

They had me under video surveillance for 2 weeks and I left the house once during that time to go to the doctor, the ATM machine to deposit a check and stopped at the grocery store for some grub. They said if I was able to do those things that I could work. Then they sent the video and their interpretation of it and sent it to every doctor I've seen in the last 2 yrs asking if after viewing it if they thought I was so disabled I couldn't work. They got a bite from my podiatrist who said I may be able to do sedentary work and walla! That's all they needed to deny my claim.

The attorney said I had a really good case. I had 5 letters from doctors that said I was disabled. The last was a physical capacity evaluation completed by a Rhuematologist. I won my SSD case in June. And the video shows me limping and using a cane and never lifting any groceries.

So over the Holiday I went into an old email account that I haven't used for 6 months and there was the email from my attorney saying that my case was denied on Dec 11. I don't rate a phone call, perhaps a letter? They suddenly forgot my current email address? Here it is Jan 7 and I still have not talked to them in person. They are avoiding me like I have the plague. Today I received my case file in a large box from Fed Ex with a letter saying that they have decided not to litigate the denial because I can't afford them. The appeal they did was on contingency. If I won they would take half of my monthly payments. Since I lost, there is no incentive for them.

Because I can't work and I'm poor I guess I can't fight this.

I'm pretty down. Any suggestions?

Interesting, What did your lawyer put in your appeal to try and get it approved? what was the reason for denial of the appeal?

 

[Robin]

I don't think you should give up at this juncture, especially if you have a SSDI claim approval under your belt. It's easy for Hartford to arbitrarily deny your appeal (they have every profit-making incentive to do it), even if they internally recognize you have a good case, in the hopes that you'll get discouraged and give up.

That's a very common tactic with insurance companies. A friend of mine was hit by a young driver while he was on a bicycle. He clearly had the right of way. The injuries to his back and neck took almost two years to resolve. Her insurance co, State Farm, initially denied his claim!! After he got a lawyer they offered him $200. Eventually he got a good settlement but it was not without much effort.

Good luck with your efforts to find a new attorney, sleepwalking! Stop in and let us know how it's going.

 

[Parismountain]

Too bad this would cost money but may be smart to do is have a vial of blood stored. Tell the insurance carrier to review the XMRV studies and that you have your blood stored to prove an onset prior to when the official standardized accepted lab test is developed. Then document document and document the cost that this denial has had upon you. Tell the insurance company you are keeping a damages journal.
Be graphic in your description in a journal, finances, emotions, physical health deterioration from the additional stress. It's just a hunch of mine and I'm no attorney but I wouldn't want to be in the shoes of a carrier who was warned that we are on the brink of discovering the source of this real disease and go up against someone who warned the carrier in a certified letter about the damages you are currently incurring because of their denial.

Hang in there and good luck

 

[kurt]

Sometimes you have to fight fire with fire.

What I would do in this situation would be to construct my own videotape evidence. Make a tape of a typical day with your CFS. Maybe track PEM for several days after a trip out of the house. Then show that to an occupational expert, one used by SSA for example who understands CFS. Then get a notarized statement from the occupational expert saying that there are no jobs in the economy that would provide suitable accommodations for your particular case of CFS. Add that to the SSA finding, and I would then find a very good lawyer who understands CFS and ask for a letter stating the grounds for a lawsuit against the disability insurance company. Then try to reach a settlement with the company, explain to them that you are not willing to give up and this will go on as long as they would like until you win your case in Federal court. You can also tell them about some of the biomarkers of disabling CFS and show that you have them, hopefully you have some evidence of that such as low cortisol or proven mitochondria dysfunction. If that matters to them you might need to get a few additional tests. XMRV is not going to help, I know people are saying that but I think not, there is no connection between XMRV and being disabled right now. What does help is tests that show low energy possibilities, 24 hour cortisol in some cases, or an adrenal stress profile of some type, mitochondria problems, maybe a liver detox profile. My liver detox profile was so bad that I used that test myself with the SSA judge and it helped. Nobody can function with detox problems like this.

In my experience, if you do not have advocates who 'get' CFS there is just no way to win these cases. They MUST understand PEM and how that limits us, and they must understand that limited mechanical functionality in CFS is not like other limiting disabilities because we have brain fog, low adrenal output, etc., and can not sustain the pace of regular work. Even sedentary work can be too much for many PWC due to the cumulative stress of that situation on our limited mitochrondrial resources.

I agree with the 'don't give up' ideas but would add that just putting out more effort to win is pointless unless you can come up with a superior strategy to the strategy being used by the insurance carrier. You are in a war and will only win the battle if your generals are better than their generals. Sad but true.

 

[muffin]

Agree with Robin

Look into getting a local lawyer and one that is really versed in LTD. I have never heard of a CFIDs person getting LTD, but we do get SSA more easily now. So, go online to www.ssa.gov and fill out the disability forms online. It takes time, and the time varies from person to person/state to state - on hearing back on your SSA. But you need to do that NOW if you haven't already. It took me almost two years to get my SSA after losing the first two rounds. But then I lucked out and had a SSA Judge that believed me and knew what CFIDS did to a person. Get your paperwork lined up, get letters from friends, work mates, etc. telling what you were like before and after CFIDS, be detailed about what you can NOT do. But get going on the SSA now to cover yourself since you didn't win LTD.

Back to LTD: I would see if another lawyer would take my case and fight the LTD company. And yes, we all do need to know what company blew you off. I can't remember if I read there was a class action suit or some other legal activities going on against the LTDs for CFIDS, but others may know. Don't give up. It hurts, it is hard but you have to keep at it. You paid into all of the LTD, SSA ,etc. and now you need what you paid into.

You have a ton of supporters here in the US. We all have been through all of this ugly stuff and we made it through - you will too. Fight as best as you can and don't give up. You have a ton of empathy, for what it's worth and even more importantly, you have people who have been through the drill with LTDs and SSA and can feed you a great deal of good info on how to win. So USE these people. I got my best friend SSA by cleaning her paperwork up, re-writing her letters (had my husband do it really) and then had some very senior people write her letters of support and she finally won - without having to go before a Judge.
She was over the moon and needed that money so bad - We all do - but she would have been in the worst shape so we killed ourselves to make sure she got it.

Fight. Ask questions, get help here - you will get either LTD or SSA - and money is money.

 

[mtnbibliophile]

Hi Sleepwalking - I know it's been a while since you last posted here, but maybe I can provide some advice to you or other readers. I used to be a lawyer until I got CFS, but I'm not giving you legal advice, just advice based on my own experience.
You can't do this yourself. If you could handle the stress and effort of conducting a successful lawsuit yourself, you wouldn't need to bring the lawsuit. Get the best lawyer you can get - look up firms that specialize in disability lawsuits in the nearest city and talk to a couple representatives. Your initial consultation should cost you nothing. They should be willing to do it on a contingency basis = to 1/3 of the award - you'd have to pay expenses but no lawyer fees unless they win for you.
I hope you kept on with your SSA case - they always turn you down the first time unless you have missing two arms or something like that. SSa is more lenient than most insurance companies about granting benefits in CFS cases. For SSA benefits, you have to show that you meet the CFS definition, that you have at least one of the medical or lab test results indicative of SSA, and to back up your own claims, you need substantiation from a daily journal, your pastor, your co-workers, etc. This is all explained in an SSA ruling called SSR 99-2p.
Insurance companies are harder, and they don't have to follow SSA rules. It is possible to win LTD cases about CFS if you present the right evidence. Self-videotaping won't work - it's too easy for them to claim you faked it. If your main problem is physical fatigue, go to a physiologist to get tested for strength and endurance - it costs money but it's necessary. If you main problem is brain fog, go to a neurocognitive psychologist and get tested, not just an IQ test but tests that measure other aspects of intelligence such as problem-solving, executive ability and processing speed. If your neurocognitive doc doesn't know anything about CFS (ask beforehand!) do a little research on the net to find some articles to send him/her. Two tests you definitely want done are called the Stroop test and the PASAT. Don't be surprised if your IQ shows up much the same as it used to even though you have major brain fog - the chenges in brain functioning are real, but they are subtle, and they're not picked up by an ordinary IQ test.
The insurance company has the right to videotape you, even on your own property. [Yup, that sucks.] On the other hand, you have the right to have them send all the records they considered when making their decision to terminate your benefits - read those thoroughly and you might spot something useful.
If you have five MDs who say you are disabled from CFS and only one who says you're not, that should be enough to get the decision overturned in court. It helps a lot if one of your MDs is a CFS specialist who can explain that the surveillance tapes mean nothing - sure, you might be able to walk for an hour, but you can't sit at a desk for 8 hours, or whatever; that CFS symptoms fluctuate, what a CFS person means by the term "tired" etc.
Insurance companies will routinely turn you down even if the evidence in your favor is overwhelming, because they know they have more resources with which to continue the fight than you do. If you stick it out, there's a chance you might be successful.
Good luck.