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    Work Disability Denied....

    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!!

    #2
    My post will not be helpful for your situation. I went throught the same thing. My employer would not allow me to continue working due to concerns of my health affecting my ability to do my job. They called me and told me to apply for STD with no return to work date. (I didn't get the hint that they were getting rid of me)

    I did pay in to disability for the past 6 years. The disability company approved for me 30 days. After that they told me I should be rested now and get back to work.

    The employer said they could not accomodate my needs and could not return to work. I used all my FMLA and was eventually let go. (first day of in June let go in December).

    I sent a lot of info to the disability company during that time. They said they didn't receive it or it was not what they needed. I had to ask doctors to send records about twice a month to appease the disability company. They refused to understand why I couldn't work.

    I gave up - I didn't have the energy to fight any more. I could not find an attorney to take on my employer or the disability company. I worked for a Fortune 500 company in a high level of management. I had an excellent work record and was a top performer.

    Now I am applying for social security disability

    Comment


      #3
      Praying that all goes well with your disability claim...

      I know it can be difficult. I had a bunch of stuff happen to me where I worked. I am now in the process of applyng for SSDI. If you look on the Social Security Disability website you might find some legal terms and specifics about motor dysfunction that might be able to help you make your point about why you can't work. Good luck and hang in there!

      Comment


        #4
        It's really frustrating all the hoops we have to jump through when we are incapable of doing our jobs due to health issues. In my situation, I pushed myself for the last year and a half.

        My job was threatened in Feb of last year for performance issues due to cognitive impairment. I got on meds and they helped for a while. In December I was warned my position was at risk again. I had been aware that I was not doing well, but have kids to feed and support.

        After much soul searching I chose to go on a STD in hope the stress was causing issues. After two weeks I was still having issues, so the doctor gave me new meds, which made me very ill. I had to quit taking, so now have extended another four weeks.

        My driving is a major issue as it is for many of us. Last week, my hub bought me a big old fashioned slow cruiser bike to ride around our neighborhood to run errands. He told me I cant really get hurt on the sidewalk, and cannot get lost in our neighborhood. I guess this just says it all. I have a fifty mile a day commute.

        The kicker tho is this. I will have to beg for my last two weeks of STD to get the "bridge" to LTD and then pray they approve for LTD. But that's not all.. I have been informed this morning that while they will hold my job for 12 weeks they will only pay me for 6 weeks of STD. If my LTD is approved I will be without income for a period of 30 days. If I am lucky, and there's still a chance I will just have to "resign".

        It sucks. More than anything I want to continue to work. I love Nordstrom rack. We are not faking just so we can sit home all day. I believe those of us with medical proof of an illness such as this should be treated with dignity and respect.

        just my thoughts-- sorry guys just fired up and angry as we all should be. -- it's gets things accomplished.

        Leisa

        Comment


          #5
          Originally posted by asiel1 View Post
          The kicker tho is this. I will have to beg for my last two weeks of STD to get the "bridge" to LTD and then pray they approve for LTD. But that's not all.. I have been informed this morning that while they will hold my job for 12 weeks they will only pay me for 6 weeks of STD. If my LTD is approved I will be without income for a period of 30 days. If I am lucky, and there's still a chance I will just have to "resign".



          Leisa
          "BEG" that sums it all up. Why are we left to beg for the very benefits that we have earned? I have had several people comment how nice it is that I don't have the stress of my former job. They forget that I also do not have the paycheck or benefits.

          Comment


            #6
            What everyone needs to understand is that nobody ever wants to pay for your disability. Not your employer, and certainly not the disability insurance company that they pay to 'cover' you. The law is stacked against you, giving more rights to the disability company than you. If you are even considering that you might become unable to do your job in the next few months or the NEXT FEW Years, you need to learn everything you can STARTING RIGHT NOW about ERISA. (the employee Retirement Income Security Act) that governs employee provided disability insurance (even if you pay for it). Every single thing about the process is set up to allow the maximum number of denials over time. If you get approved right away it only means they will be working hard to deny you after you have been out of work for awhile. Every form you fill out concerning your disability and every conversation you have with you employer or the insurance company is designed to have you provide data which makes it appear you are not fully disabled. Google Erisa ~ disability insurance. and start learning today what you can do to stand a better chance of prevailing, but just know the odds are completely stacked against you. Some of these disability insurance companies pay big donations to MS organizations to insure these organizations basically ignore this issue. Good luck.

            Comment


              #7
              I am looking for a lawyer as of today

              ... because just today Metlife called to tell me that they no longer consider me disabled and I have 30 days. I had been on LTD since last July. (and before that six months on STD.) My issues are also cognitive/stress/fatigue. They consider my improved ability to walk and shop for myself as ample evidence that I am capable of getting gainful employment making six figures again.

              and I am mad as hell

              Comment


                #8
                dstreet - You are so right!! They do not want to pay...and will do everything they can to dely, defer and deny!!! To me, this should be considered fraud and illegal on the insurance and employer's part - but I know that's not life.

                I thankfully found an attorney who is taking me case!! She sent a letter two weeks ago to my employer's 3rd party admin and with cc to my employer's HR.

                They are going to be stubborn - I, too, work for a Fortune 500 - one that ironically has a current major compaign going on about how their 'employees health is so important'!!! Sending out packages of 'health' related gear, pamphlets, etc. It wouldn't make me so sick if this company didn't publicly proclaim how much they 'care' about their employee's health and wellbeing - if I didn't see the inside story of how horrible they treat those employees who do get ill or have a disease or disability.

                I fully intend to drag their name through the mud PUBLICLY if need be. I'm sick of it - not just for everything I"ve been through - but I KNOW several other employees who've been treated just the same!! And I can only imagine how many others I don't know about! They prey on people at their weakest moments - they prey on us being too sick and weak to fight them!!! And that's how they win!!!

                It's disgusting to me...pure and simple. Disgusting.

                Comment


                  #9
                  Originally posted by zeroGravitas View Post
                  ... because just today Metlife called to tell me that they no longer consider me disabled and I have 30 days. ..They consider my improved ability to walk and shop for myself as ample evidence that I am capable of getting gainful employment making six figures again.
                  Even if you hadn't improved they'd just find another way to deny you. Get an ERISA lawyer to handle your appeal. That will let them know you are serious. If the appeal isn't handled correctly you will never prevail in Federal court (which is your only recourse after they deny your appeal.) Make sure any lawyer you pick has a web page that spells out their previous ERISA victories. Your lawyer will charge you on a contingency basis. Nothing if you lose. 30% or more if you win. It's worth it though. You will never prevail otherwise.

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