My insurance refused my LTD

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peacesoul
Veteran Member


Date Joined Jan 2007
Total Posts : 2446
   Posted 1/30/2009 3:44 PM (GMT -7)   
I was on Short term disability since last June.
My rheum and I agreed I needed the time off, then agreed I should return to work, but only part time.
 
My Short term ran out and I had told the insurance I would like to work part time. They said "nope, you need to apply for LTD"
So I did!
The insurance company then sent me to an "independent" medical dr (fancy name for the dr they pay to decide my fate), and today they call to tell me this dr decided I am more than healthy enough to go back to work full time.
 
He felt by meeting me for 60 mins, that I am able to work full time (back to 42 hrs a week-up at 5AM). He did not send me for tests, all he did was ask me questions and exam me.
 
I'm guessing everyone gets refused on their first time and I will appeal
 
Has anyone else gone through this mess?
 
Insurance companies are ruthless!
My beautiful inspiration
 
The world breaks every one and afterward many are strong in the broken places


 


Lynnwood
Forum Moderator


Date Joined May 2005
Total Posts : 7019
   Posted 1/30/2009 4:04 PM (GMT -7)   
In the end, it all depends on what LTD coverage your employer purchased. The "try three times" & such you see on here is usually related to Social Security, not employer LTD plans.

Are they sending you a letter to followup the phone call? It should have directions for how to file an appeal on it. Or call and get them. Usually these things need to be appealed within 60 or 90 days.

Your appeal should include letters from your doctor as insistent as possible, along with all the supporting labwork that justifies his opinions. My company asked for all my doctor records, forms from the doctors, and 3 of "their" doctors ended up inspecting me. Those independent doctor visits consisted mostly of conversation, vital signs, and some manual testing of joint flexibility as well as feeling the joints. I doubt they ever do labwork, but maybe they do for some people.

Hope that helps a little,

Lynnwood, Co-Moderator: Lupus Forum
SLE(’00), Sjogren's Syndrome, Raynaud's Syndrome, Seasonal Affective Disorder, Depression, Herpes Simplex 1
Plaquenil, Prednisone(15 6mg), Piroxicam, Xanax, Trazodone, Boniva, Wellbutrin, Valtrex

Links: DIAGNOSING LUPUS (4 of 11), LUPUS INFORMATION, LUPUS RESOURCES, Donate to HealingWell, Drug Interactions

"Life is far too important to be taken seriously." –Oscar Wilde, 1982

 


Barbara Lee
Veteran Member


Date Joined Sep 2003
Total Posts : 2889
   Posted 1/30/2009 6:00 PM (GMT -7)   
Hi Peacesoul:

I just wanted to wish you good luck with filing an appeal on your LTD. I can't offer any advice on how to handle this, I've only gone through the disability route with Social Security. For that I was denied once and I hired an attorney and he appealed and I was denied again, he appealed again and I ended up having a hearing in front of a Judge. Long story short I ended up winning after waiting for 3 1/2 years.

I hope that you can get your LTD settled much quicker than my SSDI. I know Lynnwood gave you great information. Don't back down keep fighting you need to follow your doctors orders. I know it's hard not to stress out over this but try to remember the more you stress, the more likely you're gonna have a flare up. Wishing you the best, please keep us updated.

Hugs,
Barbara
dx fibro, SLE, glaucoma, cateracts, bells palsy, depression, migraine headaches, gastreopaersis, chronic anemia, RA,MDS (Blood Cancer). Tons of meds.


Melissa D.
Regular Member


Date Joined Aug 2008
Total Posts : 342
   Posted 1/30/2009 6:47 PM (GMT -7)   
Hi Peacesoul,

I am currently on short-term disability as well, I have filed for SSD and am playing the waiting game. I have heard from many folks that it is very hard to get approved for LTD, almost as hard as SSD. I think that is ridiculous because we pay the premimiums and they make it near impossible to get an approval. I have hired a company to assist me with getting my SSD approved, main reason is the way I feel I don't have the energy to fight with them and with the brain fog I experience I just know I would end up screwing up or forgetting some of the paperwork. Anyway, this company also handles the leg work for my LTD as well! They don't get paid unless I am awarded SSD, so in my opinion it is all worth it and they have a 90+% rating on getting their clients approved the first time around.

I agree with Lynnwood, call the company back and see what their appeal process is. If needed, hire one of these companies, as they are all based the same way, they don't get paid unless you get awarded.

Best of Luck to you!
Melissa
Lupus - 1997   Fibro - 2001    Sjorens  -  2007   Raynauds  -  2008
Plaquenil, Imuran, Prednisone, Synthroid, Topomax, Effexor, Norco, Prilsec, Xanex, Elidel, Restasis


Lynnwood
Forum Moderator


Date Joined May 2005
Total Posts : 7019
   Posted 1/30/2009 7:47 PM (GMT -7)   
Remember to double-check what the attorney does before you make an appt.

My SS attorney did not do private LTD stuff, only SSD.

So when my LTD tried to change their minds after 5 yrs or so, I had to find another attorney to handle the appeal to LTD.

That guy actually did both SSD & LTD -- get someone who does both if at all possible -- and yeah, they get paid a percentage of any back pay SSD or LTD you get. The SSD % is regulated by federal law with a maximum of $5,700. The LTD % I paid was 30%, that isn't regulated and is probably different in different geographical areas. The attorneys are well worth it

Lynnwood, Co-Moderator: Lupus Forum
SLE(’00), Sjogren's Syndrome, Raynaud's Syndrome, Seasonal Affective Disorder, Depression, Herpes Simplex 1
Plaquenil, Prednisone(15 6mg), Piroxicam, Xanax, Trazodone, Boniva, Wellbutrin, Valtrex

Links: DIAGNOSING LUPUS (4 of 11), LUPUS INFORMATION, LUPUS RESOURCES, Donate to HealingWell, Drug Interactions

"Life is far too important to be taken seriously." –Oscar Wilde, 1982

 


peacesoul
Veteran Member


Date Joined Jan 2007
Total Posts : 2446
   Posted 1/30/2009 8:27 PM (GMT -7)   
Ahh, you ladies are awesome
 
Lynn, When they called me to tell me, they also advised they were sending forms to my Dr directly and paper to me so I can appeal.
I told them that I wanted a details explaination of why I was refused and on what grounds.
 
From all that I read on line, it is tough to find a laywer to take on a LTD claim with private insuance. But Lynn, if you're saying you have one that does both, that is encouraging. I'm wonder here in canada the same rules apply.
 
My company is very large (1500 employees) and we have very good coverage.
And yeah, you pay the premiums and then they give you a hard time.
It's a wonder why insurance co's are considered the "devil".
 
Part of me wants to just cave and go back to work, but i know what's going to happen, I'm going to keep missing days.
 
I guess they hope I cave in?!
 
Thanks again, you guys are so helpful
 
 
 
 
My beautiful inspiration
 
The world breaks every one and afterward many are strong in the broken places


 


Lynnwood
Forum Moderator


Date Joined May 2005
Total Posts : 7019
   Posted 1/31/2009 8:35 AM (GMT -7)   
I do have private LTD -- there are no companies involved, it's a personal policy I purchased while working at a company that was too small to offer LTD.

I am assuming that similar rules apply when its a company-purchased LTD. Here in the US I'm pretty sure the only difference for the individual is whether the benefits are tax-deductible (company) or not (private).

It was difficult to find the needed LTD attorney - I asked a few friends who are attorney's and they asked around with their law school contacts, and eventually one, a very good one, popped up. But these guys know insurance laws & insurance commissioners and work often with the same set of insurance companies -- an entirely different world than the US SSD.

Lynnwood, Co-Moderator: Lupus Forum
SLE(’00), Sjogren's Syndrome, Raynaud's Syndrome, Seasonal Affective Disorder, Depression, Herpes Simplex 1
Plaquenil, Prednisone(15 6mg), Piroxicam, Xanax, Trazodone, Boniva, Wellbutrin, Valtrex

Links: DIAGNOSING LUPUS (4 of 11), LUPUS INFORMATION, LUPUS RESOURCES, Donate to HealingWell, Drug Interactions

"Life is far too important to be taken seriously." –Oscar Wilde, 1982

 


peacesoul
Veteran Member


Date Joined Jan 2007
Total Posts : 2446
   Posted 2/6/2009 7:16 AM (GMT -7)   
What a NIGHTMARE! Learning about LTD and what others have gone through seems like a nightmare
 
I'm reading stories about how insurance co's refuse people who have had heart attacks, strokes, or other very serious disabilities.
I read a story about one guy who has CFS and his dr told him to get out more in the garden. he did and the insurance took video of him and cut him off from LTD claiming "if he was ok to work in his garden, he was ok to be at work"
 
I've been in contact with a disability lawyer and he directed me to a GREAT site. On this site I read how only 10% of LTD are settled and those 10% are scrutinized with constant requests for medical papers or test. And they are usually under constant surveillance from a private investigators.
 
Lupus is so far down on the scale of illnesses insurance co's even care about, I'm wondering if it's best if I make one appeal and if I am denied again, to just return to work. Working would prob hurt less than fighting an insurance company for years.
 
Here is the site if anyone else needs help. There are actual lawyers and dr's posting on this site helping others
 

My beautiful inspiration
 
The world breaks every one and afterward many are strong in the broken places


 


Serina
Regular Member


Date Joined Aug 2008
Total Posts : 431
   Posted 2/6/2009 10:23 AM (GMT -7)   

Is it hard to be a moderator?  I didn't ask to do this, because of being sick so much and not being able to respond everybody, and now it is worse.  another stroke, another episode that they do not what to call it.  but it appears to me to be DID, but I could be wrong.

It will be really good if the home health agency can help me.  If they would just help me to do my house work, they don't have to do it all by themselves.  I think if I can get this one computer room clean would be enough.

maybe I will look into that again and ask about being moderator.  I know that it is good to have the moderators.  I take mistakes and they correct me.  Would I be able to remember the rules, if I needed to speak to people? 
hester
Lupus diagnosed 1996, Fibromyalgia diagnosed 1996, Heart by-pass 1998, breast cancer 2000, stroke2002, vascular surgery 2005, heart attack in 2007, and had a stint put in, Sjogren's Syndrome 2008, Stroke 11-4-08
 
******
aspirin, multivitamin, Arthrotec , Meclazine ,  plaquinil, Metoclopomide, Doxepin , Metoprolol, synthroid,  Amlodipine, Crestor, Lasinopril, Plavix, phenagrin,  Restasis  


peacesoul
Veteran Member


Date Joined Jan 2007
Total Posts : 2446
   Posted 2/26/2009 7:35 AM (GMT -7)   
Just an update!
 
I'm going back to work next week. I decided I will not fight the insurance company. They win!
 
I went to see my rheumy last week and he said he had enough evidence to fight the LTD claim since the Insurance dr's report was very flawed. They also did not get the report from my therapist to show depression.
 
I went to see a disability lawyer who told me, if I did get approved for LTD, the insurance company would continue to harass me for paper work and could drag the case out for month and months. I need a pay and don't have months and months! They would also have a PI following me around snapping pics and if I did so much as get groceries (Which I live alone and have to do everything on my own) the insurance company would cut me off claiming if I am ok to lift bags, I am ok to work.
I also work out at the gym 3 days a week and the laywer told me I would have to give that up!
I refuse to me a slave to the insurance co.
 
My head was SPINNING and I thought, wow, it's much easier just to work.
 
My company is going to integrate me back into working, reinstate my former pay, benefits and seniority. They cannot give me my former job since I was gone for over 6 months and they gave the job to someone else. Which sucks because I was professionally trained for that job and my company paid a lot of mulla to send me to school. So not sure what my new job is going to me, but they assured me it would be a lot less stressful than my corporate buyers job.
 
Not sure how I'm going to work sick, but I gotta do what I gotta do
 
Wish me luck!
 

My beautiful inspiration
 
The world breaks every one and afterward many are strong in the broken places


 


Lynnwood
Forum Moderator


Date Joined May 2005
Total Posts : 7019
   Posted 2/26/2009 9:27 AM (GMT -7)   
Good luck!

I'm sorry that is what the LTD attorneys had to say -- but they are usually the best at predicting what a particular insurance company might keep on at you about. I also have heard that LTD bought by a company has less coverage than one paid for privately (I bought mine myself).

My LTD does have someone come watch me for a day or two once in a while -- but since my claims don't say I can't carry stuff, they can watch me go the the grocery all day long if they like! (Of course, all day long would not be possible due to my lack of stamina, concentration, and fatigue -- which they know about and which actually do keep me from shopping). I still go to the gym when I can (PT advised by Drs, haha!) but it's a private gym and they can't get in to see what I do -- all I'm up for right now is 30-45 minutes of walking anyway.

I'm glad your company is going to work with you -- lupus, at least for me, is triggered as much by my lack of self-respect (I got my self-respect from my profession) as anything, so working is sometimes better than not!

Cheers,

Lynnwood, Co-Moderator: Lupus Forum
SLE(’00), Sjogren's Syndrome, Raynaud's Syndrome, Seasonal Affective Disorder, Depression, Herpes Simplex 1
Plaquenil, Prednisone(15 5mg), Piroxicam, Xanax, Trazodone, Boniva, Wellbutrin, Valtrex, Vicodin, Prilosec
Links: Diagnosing Lupus (4 of 11), Lupus.org Info, Lupus Resources, Help HealingWell, Drug Interactions

Life is far too important to be taken seriously. –Oscar Wilde, 1882


peacesoul
Veteran Member


Date Joined Jan 2007
Total Posts : 2446
   Posted 2/26/2009 11:22 AM (GMT -7)   
Hi Lynn, thanks for the reply

My self esteem and self worth went way down when I had to stop working. I'm excited to go back and be in the "world" again, but TERRIFIED all at the same time.
My gym is private but is surrounded by windows that look in to every part of the gym.
It ticks me off that these insurance co's play like this.
As long as my company keeps an opened mind and supports me through this. I'll be ok

And I also have to keep in mind, this job is temporary since in about 18 months I'll have my naturopathic certificate and will work in that field.

I'm taking a deep breath and jumping back in
My beautiful inspiration
 
The world breaks every one and afterward many are strong in the broken places


 


Melissa D.
Regular Member


Date Joined Aug 2008
Total Posts : 342
   Posted 2/26/2009 12:47 PM (GMT -7)   
Peacesoul,

I'm sorry to hear the stress and harassment you have been put through with your LTD company. It truly is a shame that we or our employers pay for these premimums and we get treated so poorly because insurance companies don't want to pay out. I too have heard many a horror story.

I am currently on short term disability, have applied for SSD and will be applying for LTD in a few months, I pray that I am not put through this torture as well. My rheumy has already written in his notes that get sent to MetLife that part of reason he feels I cannot get well and the reason he feels I have begun having anxiety is because I am so worried about my job and about keeping my short-term disability date "approved." I was rather shocked when I received a copy of the office notes, but he is absolutely right, I mean how can we get well if we have the constant worry over our heads that we could loose everything tomorrow? We have to have our benefits, we have to have a paycheck of some sort to keep going and these are all things we worked hard for, for many years and are entitled to. There is not a day that goes by that I don't feel I have to do something to make my insurance company happy, or that it isn't in the back of my mind. It is almost a form of harassment and I'll never get well at this rate!

If you go back to work and feel as though it is something you are not able to handle, by all means go forward with the LTD since your doc feels he has adequate information to get you approved. What these companies are doing to us is not right, they should be sued!

Do you mind telling me if your company is the same as mine? MetLife? I just want to know what I am up against if it is that's all. If you don't want to state either way I understand.

Take care of yourself and don't over do it.

Melissa


Lupus - 1997   Fibro - 2001    Sjorens  -  2007   Raynauds  -  2008
Plaquenil, Imuran, Prednisone, Synthroid, Topomax, Effexor, Norco, Prilsec, Xanex, Elidel, Restasis

Post Edited (Melissa D.) : 2/26/2009 12:50:11 PM (GMT-7)


peacesoul
Veteran Member


Date Joined Jan 2007
Total Posts : 2446
   Posted 2/27/2009 8:20 AM (GMT -7)   
Hi Melissa. My company is Sunlife. trust me, they've not made anything sunny for me ;-)
 
And I agree with you 100%, how the heck can people get well when they need to worry all the time about when/if they are going to be cut off. When I was on STD, Sunlife was always harassing me for paper work, then would cut me off for 5 weeks until they reviewed the same paper work they asked me for 10 times. They are DESPICABLE!!!!!!!!!!
It is a form of harassment and there is NOTHING anyone can do except sue them in a court of law but in the meantime be out all kinds on money.
 
Here is a great site I found and posted on. You may need this site when you apply for LTD. There are lawyers that help with inquiries on this site
Another good one just to read
 
I live alone and would have to go 5 weeks with no income and then bang, they would cut me off. I had to borrow money, use up savings etc. I was SO SO SO humiliated.
But like the lawyer I spoke to said, the insurance co's do this so the patient does getter sick, b/c the sicker the patient is, the less strength they have to fight them.
 
Woman who are entitled to materity leave have better protection than people who get sick. And getting sick is NOT a choice. Our governments need to have better laws to protect people with illness.
 
 
Keep me posted on your progess ok?
 

 
My beautiful inspiration
 
The world breaks every one and afterward many are strong in the broken places


 


Melissa D.
Regular Member


Date Joined Aug 2008
Total Posts : 342
   Posted 2/28/2009 12:36 PM (GMT -7)   
Hi Peacesoul,

I've never heard of Sunlife, but I will certainly remember them now! Yes, our government needs to do something to protect individuals like you and I from these companies. You are correct, pregnant women and their spouses these days have more rights and benefits than someone who is inflicted with an unwanted illness or disease and we get treated many of the time as though it's our fault!

I will definitely keep you posted on my situation.

Melissa
Lupus - 1997   Fibro - 2001    Sjorens  -  2007   Raynauds  -  2008
Plaquenil, Imuran, Prednisone, Synthroid, Topomax, Effexor, Norco, Prilsec, Xanex, Elidel, Restasis

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