This is my 3rd claim - first was in 2007 and was denied based on technicality of being submitted too late. Our disability is administered by 3rd party Sedgewick James. My employer overruled internally because this was my first disability and I was never advised to file; my FMLA request for my entire time out had been pre-approved and still was never told to file until 3months AFTER I had returned to work.
Second time was in 2009 and they denied at first. Then I appealed and they approved.
Now this is my 3rd claim 2010 - as things have progressively gotten worse (and I'm still out). This time, they again denied my first submission. Which I started off with the type of information provided in my previous appeal - but they denied anyway. I submitted an appeal in which with my original request and the appeal they have MORE supporting information than previous claim - yet they are denying based on 'lack of clinical evidience'.
This means lack of my doctor exam being able to 'find' clinical evidence of my fatigue, loss of energy, lack of strength, migraines, dizziness, nausea, etc. Even though they've been advised by my doctor what my symptoms are that are preventing me not just from working, but actually being able to even take care of my own personal need from day to day (like brushing teeth, getting meals, bathing, etc) and my recent spine MRI showing my SOLID 12CM lesion on my Cspine....they still are denying.
I need to know if anyone knows of a good attorney to fight this. Based on what they've narrowed this down to - there is nothing I can submit to appease them. Although they have a Board Certified Neuro (for hire - I used to work in Med-Legal claims for 8 yrs so I know the kind of docs they are using) I'm positive this doctor does not outweigh my TWO Neuro's MS expertise. But again - they are not going on validity of claim, disease - they are going on a technicality.
The one thing I can ask is what 'clinical evidence' was my last claim's approval based on - because as I said, this time there has been MORE supporting evidence provided than previous. So this would show a discrepency in how they are processing and handling claims. And if they approved the previous one w/o this so-called clinical evidence - how does this one now get denied?
My doctors have retorted their prevous denial points - that I hadn't had an MS flare up since 2004 - explaining I'm in Secondary Progression w/o relapse but how the disease still progresses and becomes worse over time. I've been dx'd since 2003 and had symptoms as far back as 1994 - so I'm now 16+ years into this disease. I'd say with my history and where my lesions are (primarily spine, brain is almost clean) I've done damn well in being able to keep working full time and continue to live a decent life.
But I reached a point last year where things changed drastically and I could no longer function as I was able to before. As I lay in bed writing this, exhausted and having trouble focusing - having been in bed and sleeping all day, feeling very 'ill', etc. sitting in the same f'ing pj's I've been in for over a WEEK straight - because that is how utter ill, exhausted and weak I am day to day - it's extremely upsetting that this 3rd party administer seems to think they know better than my treating physicians - who would not risk their careers for insurance/disability fraud of one patient - so think I CAN continue to work when I can't even take care of my most basic needs! It's humiliating and I'm so angry but it's very hard for me to fight back when I can't even take care of myself.
Anyway - I guess part of this is ranting but I really do need to know how to fight this because it's wrong. This company has a history of automatically denying claims regardless of their validity and then trying to continue to deny any appeals based on any technicality they can find. It's not about the employee's health and well being, it's about them trying to save my employer money so they can retain their stupid contract with them.
They have shown underhanded practices - descrpencies in how claims are handled (not only from employee to employee but even from how each of my own three claims have been handled for the same, incurable, ongoing disease!!). I would even consider making this class action law suit.
Kaiser is partly at fault for neglectful treatment from my previous Neuro - and although his original comments hurt my claim significanlty - he DID send a follow up letter explaining why/how I am still in this position w/o a relapse. But it doesn't excuse the damage done and the way what he did affected my treatment and care from him and other doctors based on his notes.
It was after that that I was able to get another doctor to finally do a spine MRI - and that's when the 12cm lesion was found...and ever since then comments from the doctors I've seen and spoken to all are taken back that I have a lesion that large and that it can do significant damage - and seem a bit surprised that is my case since I'm still technically able to walk on my own, etc. I just can't do it for very long and many days - I can't really get out of bed or even hold myself up in a sitting position!!
I'm in Northern California - does anyone know of any specific attorney's who specialist in this type of disability. This is against my employer - the state has approved my disability all along based on my doctors submissions and completions of their forms, etc.
Not only does this impact my benefits that our company offers - I will get partial payment and keep my health benefits (which I am in dire need of, obviously) but it secures that I don't get 'fired' for my 'attendance'. If my claim is ultimately denied, they can fire me for being out. And then everything I've worked my *** off for over the past 11yrs with this company is lost.
Up until this and even between my previous disability claims, I have always had an impeccable reputation as a hard worker, high ethics, and able to produce high and accurate output with expedience. My manager told me a few times, my 50% is everyone elses 100%. Not bragging, I'm just saying that I've always been a kick *** employeee and taken my job and projects very seriously. My job was the very last thing to go - I let everything else slip so I could try my hardest to keep working. I only stopped because I reached a point where with sleeping when I wasn't trying to work - I was able to work less and less until finally, I couldn't even get 2hrs of work done throughout an entire day's time.
My job allowed me to work from home, everything I did was based on my lap top and calls and I had a very flexible schedule. So this allowed me to keep going much longer than I may have otherwise been able to. But I hit the wall and literally could not keep working (because they would not accept me working less than 2hrs each day). So this is where I am.
Of course there are many details left out - way way way too much to include here. This is long enough as it is.
Any help or advice anyone has would be greatly appreciated. We already asked the National MS Society and all they did was give us this 3 page list of attorneys. No information on them or who is really versed in this kind of case, etc.
Thanks for listening!!
Second time was in 2009 and they denied at first. Then I appealed and they approved.
Now this is my 3rd claim 2010 - as things have progressively gotten worse (and I'm still out). This time, they again denied my first submission. Which I started off with the type of information provided in my previous appeal - but they denied anyway. I submitted an appeal in which with my original request and the appeal they have MORE supporting information than previous claim - yet they are denying based on 'lack of clinical evidience'.
This means lack of my doctor exam being able to 'find' clinical evidence of my fatigue, loss of energy, lack of strength, migraines, dizziness, nausea, etc. Even though they've been advised by my doctor what my symptoms are that are preventing me not just from working, but actually being able to even take care of my own personal need from day to day (like brushing teeth, getting meals, bathing, etc) and my recent spine MRI showing my SOLID 12CM lesion on my Cspine....they still are denying.
I need to know if anyone knows of a good attorney to fight this. Based on what they've narrowed this down to - there is nothing I can submit to appease them. Although they have a Board Certified Neuro (for hire - I used to work in Med-Legal claims for 8 yrs so I know the kind of docs they are using) I'm positive this doctor does not outweigh my TWO Neuro's MS expertise. But again - they are not going on validity of claim, disease - they are going on a technicality.
The one thing I can ask is what 'clinical evidence' was my last claim's approval based on - because as I said, this time there has been MORE supporting evidence provided than previous. So this would show a discrepency in how they are processing and handling claims. And if they approved the previous one w/o this so-called clinical evidence - how does this one now get denied?
My doctors have retorted their prevous denial points - that I hadn't had an MS flare up since 2004 - explaining I'm in Secondary Progression w/o relapse but how the disease still progresses and becomes worse over time. I've been dx'd since 2003 and had symptoms as far back as 1994 - so I'm now 16+ years into this disease. I'd say with my history and where my lesions are (primarily spine, brain is almost clean) I've done damn well in being able to keep working full time and continue to live a decent life.
But I reached a point last year where things changed drastically and I could no longer function as I was able to before. As I lay in bed writing this, exhausted and having trouble focusing - having been in bed and sleeping all day, feeling very 'ill', etc. sitting in the same f'ing pj's I've been in for over a WEEK straight - because that is how utter ill, exhausted and weak I am day to day - it's extremely upsetting that this 3rd party administer seems to think they know better than my treating physicians - who would not risk their careers for insurance/disability fraud of one patient - so think I CAN continue to work when I can't even take care of my most basic needs! It's humiliating and I'm so angry but it's very hard for me to fight back when I can't even take care of myself.
Anyway - I guess part of this is ranting but I really do need to know how to fight this because it's wrong. This company has a history of automatically denying claims regardless of their validity and then trying to continue to deny any appeals based on any technicality they can find. It's not about the employee's health and well being, it's about them trying to save my employer money so they can retain their stupid contract with them.
They have shown underhanded practices - descrpencies in how claims are handled (not only from employee to employee but even from how each of my own three claims have been handled for the same, incurable, ongoing disease!!). I would even consider making this class action law suit.
Kaiser is partly at fault for neglectful treatment from my previous Neuro - and although his original comments hurt my claim significanlty - he DID send a follow up letter explaining why/how I am still in this position w/o a relapse. But it doesn't excuse the damage done and the way what he did affected my treatment and care from him and other doctors based on his notes.
It was after that that I was able to get another doctor to finally do a spine MRI - and that's when the 12cm lesion was found...and ever since then comments from the doctors I've seen and spoken to all are taken back that I have a lesion that large and that it can do significant damage - and seem a bit surprised that is my case since I'm still technically able to walk on my own, etc. I just can't do it for very long and many days - I can't really get out of bed or even hold myself up in a sitting position!!
I'm in Northern California - does anyone know of any specific attorney's who specialist in this type of disability. This is against my employer - the state has approved my disability all along based on my doctors submissions and completions of their forms, etc.
Not only does this impact my benefits that our company offers - I will get partial payment and keep my health benefits (which I am in dire need of, obviously) but it secures that I don't get 'fired' for my 'attendance'. If my claim is ultimately denied, they can fire me for being out. And then everything I've worked my *** off for over the past 11yrs with this company is lost.
Up until this and even between my previous disability claims, I have always had an impeccable reputation as a hard worker, high ethics, and able to produce high and accurate output with expedience. My manager told me a few times, my 50% is everyone elses 100%. Not bragging, I'm just saying that I've always been a kick *** employeee and taken my job and projects very seriously. My job was the very last thing to go - I let everything else slip so I could try my hardest to keep working. I only stopped because I reached a point where with sleeping when I wasn't trying to work - I was able to work less and less until finally, I couldn't even get 2hrs of work done throughout an entire day's time.
My job allowed me to work from home, everything I did was based on my lap top and calls and I had a very flexible schedule. So this allowed me to keep going much longer than I may have otherwise been able to. But I hit the wall and literally could not keep working (because they would not accept me working less than 2hrs each day). So this is where I am.
Of course there are many details left out - way way way too much to include here. This is long enough as it is.
Any help or advice anyone has would be greatly appreciated. We already asked the National MS Society and all they did was give us this 3 page list of attorneys. No information on them or who is really versed in this kind of case, etc.
Thanks for listening!!
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