Health Insurance Issues
October 15, 2011 - 5:22pm
LTD rejection by employer insurance
Hi everyone,
My LTD claim was rejected by my employer's insurance company.This is an employer plan where pretax dollars are deducted from my paycheck.I worked for that employer for 10 years.Have had 2 failed lumbar decompression surgeries.Continue to have pain,sensory and motor loss which is documented.STD was paid for the 12 week period after my last surgery.
The insurance company said that my surgeon did not supply the information supporting our claim that I could not perform my normal work.
This surgeon who has been treating me now for 1 1/2 years is from a world class institution in the mid west USA.
I've hired an attorney towards the appeal of the denial.This is not just IMO.
Anyone else confront a similar situation?
Do I have any other recourse?
All help/advice appreciated
_____________
Violation of Forum Rules
User login
New forum topics
Clinical Trials
Who's online
Connect with Us
HI,
First let me say welcome to spine-health. Have a look around and you will find others whom are dealing with insurance issues. You have the right to file and appeal and also have copies of all the documents that were used in the determination of the opinion. Have you looked at the document your surgeon submitted on your behalf? Be sure you also have a copy of the rules of the LTD for your employer. If all else fails you also have rights to appeal to the state insurance fund whom governs all insurances for your state. Keep in mind it is not a short process. Are you still employed by the employer? If so what is paying you at the current time? Is there any possibility your not still covered by the LTD, if your not employed?
Just thought I would stop by and welcome you to spine-health. Let us know how it works out. Take care.
Under LTD, most plans are governed by ERISA which is a legal act that outlines how to appeal, time-lines, etc. If you have an ERISA LTD attorney they'll be aware of all that and will be seeking out supporting medical documentation to appeal. In addition your detailed denial letter will tell you when you must appeal, etc. Please know that if you chose to use an attorney they must notify LTD they are representing you, and at that time the insurance company will only communicate with the attorney.
If you had STD and it was with the same insurance company as your LTD it would be rare for them to deny LTD unless the LTD "definition of disability" is such that LTD believes you are capable of working.
Be sure to get a copy of the EXACT plan under which you are covered (not including any changes made since the day you first went out of work due to disability). HR/Benefits at your employer should be able to get you the correct plan document.
Please be sure the attorney specializes (and preferably) in employment/ERISA/STD-LTD law.
Rt. Total Knee Rplcmt 09/2011
L3-S1 PLIF '10; L4-S1 PLIF '93; L5-S1 PLIF '87
C5-C7 Foraminotomy '08; C5-C7 ACDF '06
Bilateral knee arthritis. Bilateral CTS.
Thanks everyone-I'll ask if the attorneys are ERISA LTD experienced.Hope so for $375 per hour!!
Violation of Forum Rules
there is a site that may help you, they have a book on appealing your LTD terminatio. The name is disabilityappealletter dot com I hope everything works out well.
After consulting (and paying) attorneys my appeal was accepted!
Question -what behavior should I adopt so as not to loose this LTD?
Also my worker's comp is going to mediation.
Like others on this forum the attitude of persistence equals power is one to uphold...
Violation of Forum Rules
Every time you see your spine surgeon or pain doctor be sure to accurately state the level of pain and incapacitation you feel, things that are bothering you, etc.
I have an agreement with my spine surgeon that I come in twice a year to discuss pain levels, symptoms, etc so he can provide LTD with information at any time they request it.
Respond timely to any requests from LTD.
They likely will require you apply for Social Security Disability (SSDI) as SSDI is offset (deducted from) LTD so it lessens LTD's financial responsiblity. Once SSDI is approved it's more likely your LTD will continue with only perhaps annual updates.
Most employer LTD plans have a two year own occ period. In the first two years of benefits you are evaluated to see if you are disabled from your own occupations. After that you must be disabled from any occupation for which you are reasonable able, trained, educated or experienced. So someone who was an accountant but took a heavy lifting job may be disabled from a back problem for 24 mo, but after that LTD will evaluate if the person can go back to their prior occupation of accounting.
Get a copy of the EXACT policy under which you are covered and read the first few pages which lay out the DEFINITION OF DISABILITY where the own occ and any occ periods are defined.
I went out of work 4/2009. Was on STD through 10/2009 and the LTD started 10/2009.
10/2009-10/2011 Own Occ period
10/2011 to SSNRA Any Occ period
Applied for SSDI via atty 08/2010 per LTD request
Denied 12/2010
Appeal (reconsideration) via atty 01/2011
Recon denied 06/2011
ALJ hearing requested 07/2011 via atty
ALJ hearing now scheduled for 02/2012
The way SSDI works
*last worked 04/2009
*5 full calendar mo waiting period
*May, June, July, Aug and Sept
*SSDI may begin 10/2009
*Medicare begins after 24 mo of SSDI
*24 mo SSDI pas of 10/2011
*Medicare 11/2011
Right now LTD has not made my Any Occ decision yet, it's likely they are waiting to see what happens with my SSDI hearing.
IF SSDI is awarded benefits will be paid back to 10/2009 (if SS agrees I was disabled 4/2009) and all back pay will be paid to LTD. Then going forward I get SSDI and LTD.
Rt. Total Knee Rplcmt 09/2011
L3-S1 PLIF '10; L4-S1 PLIF '93; L5-S1 PLIF '87
C5-C7 Foraminotomy '08; C5-C7 ACDF '06
Bilateral knee arthritis. Bilateral CTS.
Smaller companies with limited resources, to war prevention addresses exposures of the Premier League, ironically may face greater financial risk. War insurance provides coverage of the Premier League defence and prior, current and prospective employees even alleged to cover claims of compensation for breach of its legal rights.
Banned
It is difficult situation you are facing with your health. Major operations are done and you are in need of good support. I think the attorney will help you find a solution. I can suggest you to invest in such areas where there is a guaranteed income at some point.
Regards,
Standards agreement and posting rules
Please note that Spine-Health reserves the right to edit any messages posted or submitted or e-mailed to the Company and use them for content on the website or in other company materials. No e-mail solicitation or advertising of other companies, products, services, or web sites is permitted in the Spine-Health.com forums.
Post Edited by Authority Member Liz
I have worked in three different medical practices over fifteen years....I have never had an employer bill my kids or husband for that matter. Even if they bill the insurance. The trick is you aren't supposed to bill insurance but not bill the difference. BUT they still do it!
SPAM REMOVED, NO CONNECTION WITH INSURANCE
Standards agreement and posting rules
Please note that Spine-Health reserves the right to edit any messages posted or submitted or e-mailed to the Company and use them for content on the website or in other company materials. No e-mail solicitation or advertising of other companies, products, services, or web sites is permitted in the Spine-Health.com forums.
Post Edited by Authority Member Liz