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    Denied LTD

    Count me in the crowd screwed by employer's insurance carrier. A little advice. When the carrier contacts you, they have 45 days pet Erisa to have an initial decision. This can be extended at the request of the claimant for another 45 days.

    When I spoke to them, I told them I couldn't get the neuro functional assessment until a specific date which was after this date. I was told no problem, take them then. They went ahead and reviewed claim with one office visit, which lacked dentail and my neuropsych assessment.

    Based on this they denied. When I called back, they said no problem, I cold send these in after my appt still. Of course what they didn't tell me was it would then count as my appeal. I told them I wasn't going to rush it then, as I want my full record included. They then offered to rushy review so that another decision could be made by the eligibility date for payment ( a few weeks). Scare tactic for loss of employment. Once again, would have been my appeal review. Finally, last tactic was to offer to pull my PT progress reports and review.

    They tried every trick to get me to rush appeal review. Thankfully, I talked to my lawyer before this and he warned me of each tactic. I told them it would be handled with benefit of counsel and that I felt extremely misled on how they handled my claim. Good thing is that lawyer thinks I can add that to the appeal as further grievance. I guess the next 180 days will be painful.
    Kathy
    DX 01/06, currently on Tysabri

    #2
    pennstater, after reading your post, I'm relieved that you have an LTD attorney representing you. Carriers will sometimes be a bit more agreeable when there's an attorney involved.

    The 45 day ERISA requirement for the carrier to give notice is not unique to group LTD insurance. All insurance policies must allow the carrier reasonable time to review claims, medical records and make claim determinations. But it's important to have an ERISA attorney representing you.

    The carrier understands the importance of Delay, Deny and Document only what is legally required and/or favorable to their case. Odds are in their favor even without the deceptive tactics, after all they are dealing with very ill individuals lucky to remember their next doc appointment.

    For anyone reading this, remember to document everything in writing; don't communicate verbally if possible, but if you do, request they follow up in writing and verify everything the carrier tells you in writing.

    At the very least keep a detailed LTD carrier 'diary' of dates, times, names and details of conversations, and get a committment for a date the writen confirmation will be mailed to you. Legally, if it's not in writing, your credability can be questioned.

    We can learn a lot from our shared experiences, so do keep us up dated, and best of luck.

    Comment


      #3
      Yes - CAUTION is the key. I have good notes and dates/times of calls. But since I was sick with bronchitis, I wasn't diligent about documenting and confirming. My lawyer was trying to not run up my bill and stayed out of it, but will now be on point.

      I spoke to my plan administrator prior to follow up call to claims manager. He was surprised they made a decision if I had informed them that I couldn't get to the doctor for assessment until after the 45 day window. He also indicated that sounded like an extension should have been granted since I specifically stated I could not get the detailed functional and behavioral assessments to them until after the initial 45 day window. He said they should have contacted me. I told them a separate person called, but I told them the same thing - that I had the appointments late January. So if they pull phone log recordings, it's on the tapes.

      That being said, while I would like to trust the plan administrator, I won't. He sounded sincere in his dismay of how it was handled, asked who the manager was, and also told me to focus on getting better. But I am jaded and don't trust anyone involved except my lawyer and doctors.

      Interestingly enough, my lawyer said the longer the appeal window stays open, the more likely they are to approve. So he said if I can financially hang on, he won't rush and will spread the work/billing out rather than all at once. I never heard that before.

      Any others have success with an appeal as it stayed open longer into the 180 day window?
      Kathy
      DX 01/06, currently on Tysabri

      Comment


        #4
        I know most customer service calls have a disclaimer 'this call may be monitored or recorded for future training and quality assurance purposes'?, but I think most insurance co's use computer based system, usually one called 'INFO' to transcribe contemporaneous notes of conversations with you.

        I hope your conversations are recorded, retained and retrievable, that would be irrefutable documentation in your favor. Which is exactly the reason I think the INFO system is their primary source of documenting telephone conversations.

        Is the benefits plan administrator your employer, or a 3rd party benefits plan administrator under contract with your employer, or the insurance carrier's title for a designated insurance admin for your employer's LTD plan?

        Usually 3rd party benefit plan admin's represent your employer, and your interest in a dispute with the insurance carrier. But I agree with you, I wouldn't trust any one of them as far as I could throw them.

        Comment


          #5
          I am not sure about the telephone recording system. I guess we'll find out.

          The plan administrator is the HR Benefits director for my employer, soon to be former employer. He has been genuine in the past and has referred to me as the type of employee a company hates to lose. He has always offered to help in the past and got on both the STD and LTD claims managers when they were dragging their feet on transitioning the claim. That being said, I know to be skeptical.

          I probably won't have updates for awhile, but will let you know when things progress.
          Kathy
          DX 01/06, currently on Tysabri

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