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Nothing is easy (short term leave approval ....)

AnonymousUserAAnonymousUser Posts: 49,671
edited 06/11/2012 - 8:26 AM in Back Surgery and Neck Surgery
I told my husband last night that it seems unfair that you have to fight every single step of the way to have your various insurance plans cover your back surgery. ~X( I wont go into great detail in this post about the fight for initial approval from my health insurance (last min denial / peer to peer review / sleepless nights :SS AND THEN final approval). And then confusion with my prescription coverage causing denial to pay for fentanyl patches with final resolution that they were covered. And now on to my short term disability claim ...

Having worked in the benefits area at one time, I know that you have to meet appropriate deadlines and have all your paperwork in. I submitted my initial short term leave claim 30 days prior to my surgery. I filed it as both short term and FMLA to ensure that I received max job protection available. I followed up when I returned from the hospital to ensure that appropriate information was en route post surgery. Great ... seems like all should be set.

On December 31, I received a call from M--L--- Insurance indicating my claim was approved from Dec 10 (surgery date) to Jan 7 and that I would receive a letter indicating additional data needed to extend the claim. On January 6, I received a letter indicating about 5 additiional pieces of documentation that was required to continue my claim. I called my doctor's office frantically and began pushing for data to be sent. :T

Then I got angry! I stepped back and thought about the number of years that I have paid for STD (short term disability insurance), and the fact that I had handled all my papers with appropriate notice. It was not reasonable for Met to push for information in less than 5 business days over the holidays! I called Met and was eventually transferred to my case manager. She agreed that the turnaround times requested were not reasonable. She also agreed to extend the claim for another 4 weeks based on our phone discussion. The good news is that I now have 8 weeks of leave in total approved.

The BAD news is that I have had to fight every step of the way to get my benefits to pay for the medical services in question. There was no argument that this surgery was needed once the right people talked. The RX coverage was an error with the pharmacy. The STD coverage was perhaps just stupidity. However, if I did not fight, each of those challenges could have caused delays in medical care, increased expense or significant loss of income. It some how does not seem fair that you have to argue to get benefits due.

Sorry this became a long rant. Just wonder if others have struggled as well.


  • I have "them" for long term disability and every time I turn around I have to fill out more paperwork. I just had major back surgery for goodness sakes. I wish they'd leave me alone. For months they've been sending me letters saying I need to apply for SSDI and I keep telling them I have to be off work for atleast 12 months before they will even consider covering me and I plan to be back to work by then. Oh because I said that maybe I need to fill out a new form because I must be feeling better. X(
  • The only reason a LTD company advises they will help someone file for SSDI is because it's less they have to pay each month if your approved. I was told I needed to file for SSDI when I was ending my STD and was going back to work part time the following week. I never even had to go on LTD and they were hounding me to apply for SSDI. Of course I advised them which road they could drive on.

    My LTD benefits are more than SSDI, so if I were to be approved for SSDI, the LTD company would only have to pay the difference between the two each month instead of the whole amount.
  • You crack me up. =)) I can only imagine that conversation!

    I'm glad I had the ability to work from home so I didn't have to do any of this. But I had to fight with my insurance company for every claim they paid. They've refused to this day to pay an ambulance bill. They refused to pay the anesthesiologist. I guess they thought I should have had surgery wide awake. Even the claims rep I talked to had to laugh at that one and finally they paid once I pointed out to them there is a law in my state that says "Yes Mr. Insurance Co. you are legally obligated to pay for anesthesia."
    Now I'm trying to figure out how to go from working to SSDI. Not because of my surgery though. Another condition that I have has made me focus on the "what if's".
    It is frustrating that we pay our premiums and then have to fight for our benefits that we paid for.
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