It appears that your MSWorld session has not been initiated or has expired. To renew your session, please click here, then click 'Logout' on the right hand side and log back in again.

Go Back   MSWorld Forums > MSWorld Message Boards > Social Security Disability Questions Answered by Attorney Rich Feingold
Register FAQ Calendar Guidelines Mark Forums Read Login

Social Security Disability Questions Answered by Attorney Rich Feingold This board is for you to have your general questions about Social Security disability benefits answered by volunteer attorney Richard I. Feingold.

Reply
 
Thread Tools Display Modes
  #1  
Old 05-29-2013, 07:02 PM
wodita wodita is offline
Registered Member
 

Join Date: Dec 2012
Location: New Orleans, LA
Posts: 15
Denied LTD and STD is it worth appealing?

hello fellow MS'ers,

I am still new to this disease---Dx RRMS 12/2012, Copaxone 01/13. Currently minor Sx -- numbness /tingle/tightness in the right hand, some short term mem issues but not disabling...

In Feb 2013 I changed jobs for a promotion including an nice pay bump. I was also exited about the LTD and STD that this company offered. It was a generous policy that I paid for so if I needed to use it, it would be tax free....

What I was not expecting was the fact that I needed to be approved to get the LTD/STD. As you can guess, Aetna rejected my application without any consult with my Dr just based on my honesty about my MS and Type 1 diabetes on the EOI form.

Now my question is:

Is it worth the effort to appeal this decision? I am a male, 44 yrs old and in excellent health (aside from MS and Diabetes ) and I am pretty sure my Dr would provide a positive perspective on my condition.

Any suggestions are appreciated!

Thanks!
TONY
Reply With Quote
  #2  
Old 05-29-2013, 10:44 PM
Marco's Avatar
Marco Marco is online now
Registered Member
 

Join Date: May 2009
Location: Austin, Texas
Posts: 910
Had you lied on your application and then needed to use the policy. Aetna would have reviewed your medical records and denied your claim because you fraudulently entered the contract.

So you applied for a disability policy with Aetna and they denied covering you? Is the basis of your denial the preexisting conditions of MS and Diabetes or something else?


Is this an ERISA disability policy?

Did you attempt to purchase the policy directly from the insurance company or through the company?

I believe if you attempted to purchase the policy directly from Aetna the policy would be covered under the laws of your state. In that case you should consult a disability lawyer in your state.

If your policy was purchased directly through your employer you need to have your cased reviewed by an attorney familiar with ERISA the claims.

If you have ANY grounds to appeal the decision you should. If you don't appeal the answer is always "NO!"
Reply With Quote
  #3  
Old 05-30-2013, 12:46 PM
tspaulding tspaulding is online now
Registered Member
 

Join Date: Mar 2010
Posts: 201
Quote:
Originally Posted by wodita View Post
hello fellow MS'ers,

I am still new to this disease---Dx RRMS 12/2012, Copaxone 01/13. Currently minor Sx -- numbness /tingle/tightness in the right hand, some short term mem issues but not disabling...

In Feb 2013 I changed jobs for a promotion including an nice pay bump. I was also exited about the LTD and STD that this company offered. It was a generous policy that I paid for so if I needed to use it, it would be tax free....

What I was not expecting was the fact that I needed to be approved to get the LTD/STD. As you can guess, Aetna rejected my application without any consult with my Dr just based on my honesty about my MS and Type 1 diabetes on the EOI form.

Now my question is:

Is it worth the effort to appeal this decision? I am a male, 44 yrs old and in excellent health (aside from MS and Diabetes ) and I am pretty sure my Dr would provide a positive perspective on my condition.

Any suggestions are appreciated!

Thanks!
TONY
I am confused you had written if you need STD/LTD if would be available to you, yes always w/ docs note. So if you don't need STD now why did you apply? I had to use STD then LTD where I worked and was glad it was available for me with just doc notes. Good luck to w/ STD. Now I am on SSDI. RRMS since 95
Reply With Quote
  #4  
Old 05-30-2013, 01:42 PM
MSW1963 MSW1963 is online now
Registered Member
 

Join Date: Sep 2011
Posts: 1,361
Insurance companies and insurance agents have been using their group clients as marketing opportunities to sell "Supplemental", 'Workplace' or 'Voluntary' insurance coverage for decades now.

Supplemental, workplace, voluntary insurance coverage sold in the 'workplace' is usually individually underwriten coverage requiring completion of an application before coverage is approved, versus Group coverage which usually only requires completion of an enrollment form for the group insurance coverage to take effect.

An insurance application usually includes a disclaimer that the 'proposed insured' aka 'the applicant', understands there is no guarantee that a policy for coverage will be issued.

The 'workplace', 'supplemental' or 'voluntary' policies can be offered on a 'guaranteed issue' basis depending on the employee population, 501+ employees for example may be offered 'guaranteed issue' coverage, meaning the three medical questions on the application for insurance can be ignored and are not required to be answered by the applicant.

"Workplace", "Supplemental" or "Voluntary" policies for an employee population of 201-500 may be eligible for 'simplified issue' policies, meaning only the three medical questions will be considered as the basis for issuing the policy or declining to issue the policy.

Workplace, Supplemental, Voluntary policies for smaller employee populations will use the three medical questions to fully underwrite the the policy by requesting info from any doc you consulted and were required to disclosed in the application.

Workplace, Supplemental, Voluntary policies are individual insurance policies, not to be confused with a Group policy or Group coverage.

The employee population considered for making an offer for either guaranteed, simplified, or fully underwriten application/policy is made by each insurance company. Some insurance companies may require a minimum 10k employee population for offering guaranteed issue coverage.

There is usually a payroll deduction begin date to collect premium payments. If the policy is denied and not issued, any payroll deductions made during the 'underwriting' process, before a coverage determination was made because doc's need to retrieve your medical records etc., is refunded by the insurance company to the applicant.

Basically the disclaimer on the application that the completion of the application is no a guarantee of coverage or that a policy will be issued, eliminates any recourse if coverage is denied.

Exceptions might be if the application should have been offered on a 'guaranteed issue' basis and you inadvertently disclosed medical info that was not a basis or consideration for issuing your policy.

Lots of mistakes can occure during annual open enrollment or mid year enrollments for new hires, for supplemental policies.

For instance, the original agent may no longer be the agent of record for the group, or the agent may have passed enrollment responsibilities to new or inexperienced agents over the years. Contract language may have been mis-interperted by HR reps, who may be handling mid year enrollment of newly hired applicants.

Servicing the group may drop completely because the original agent's 'core business'=the group health plan, has been 'lost' and is now covered by a different insurance company & a new agent, who may be legally prohibited from involvement in competitor's business. None of which is acceptable, but contracts between the employer and the insurance agent/company don't always make allowences for these circumstances.

This 'decline' to issue coverage is unfortunately, probably in your Medical Information Bureau (MIB) record. Future applications for insurance you complete will at minimum know insurance coverage was denied to you in the past. It can negatively influence future coverage decisions by insurance companies.

Wishing you good luck sounds a bit lame, but if there is any good news it is that insurance companies are always interested in new business, and new products for the hard to insure population have been developed in recent years. As the previousely young and healthy population ages and health issues arise, new products will be in greater demand.
Reply With Quote
  #5  
Old 05-31-2013, 08:57 AM
wodita wodita is offline
Registered Member
 

Join Date: Dec 2012
Location: New Orleans, LA
Posts: 15
Clarification

Thanks for the information provided...

Now I can ask the question a little better......

Here is a quote from my company's benefit policy. Please note the bold section about signing up within the first 30 days....:

" You must elect LTD coverage either within the first 30 days of your employment with XXXX, within 30 days of having a qualified change of status, or during the next Benefits Open Enrollment period.

You will be required to provide satisfactory evidence of insurability (EOI) to the insurance company at your own expense. The EOI requirements are very stringent and cannot be waived or reduced.

If you have a qualified change of status and wish to enroll in or increase your LTD coverage, you must submit your request within 30 days of your qualified change of status using Employee Self Service (ESS).

The insurance company determines whether enrollment will be permitted based on information provided through the EOI process. Coverage is not effective unless the insurance carrier approves your request.

If approved, coverage will be effective the first of the month coincident with or following the date coverage is approved by the insurance company.

Note: EOI is not required IF you elect LTD coverage during your 30-day new-hire enrollment period or within 30 days of changing to regular, full-time employment status. After this period ends, EOI (at your expense) and carrier approval will be required for all new enrollments."


OK now here is where I think I screwed up.....With this LTD policy there is also a STD policy option. That option has 2 choices:

Option 1: Your weekly benefit begins after 7 continuous days of disability.
Option 2: Your weekly benefit begins after 30 continuous days of disability.

If you choose Option 1, you must fill out the EOI....I did and I think that is where I screwed up...

If I would have just picked the normal option 2 then based on the Note above I would not have needed to do the EOI.

----

So now my question is ---- Since it seems that my company policy offers "guaranteed coverage" -- No EOI, if I sign up within my first 30 days based on the Note above can I appeal to have just the basic LTD coverage based on the fact that I signed up within the 30 day window?

Or am I screwed because I got greedy and asked for more coverage with STD and had to fill out the EOI....

Based on Marco's comments I will appeal because if I dont the answer is definitely No I am just trying to set my expectations on my possible success..

MSW1963 thank you for the detailed info that was very helpful!!!

tspaulding, I hope this post explains better my situation..I am not applying to use LTD just to get coverage....

Boy has this been a lesson learned for me!!!

Thanks again for all your help!!!
TONY
Reply With Quote
  #6  
Old 05-31-2013, 12:07 PM
MSW1963 MSW1963 is online now
Registered Member
 

Join Date: Sep 2011
Posts: 1,361
NOLA here too.

wodita/Tony, there's ambiguity between the Guaranteed Issue LTD within 30 days of hire without EOI, and option 1 for SDT with EOI. I'm not sure legally if the STD EOI can be used to deny the Guaranteed issue LTD. But yes, does seem the denied guaranteed issue LTD coverage was based on your selection of option 1 STD w/EOI.

Contact the Louisiana Insurance Commissioners' office to clarify if the LTD Guaranteed Issue can be legally 'waived' based on the STD EOI.

The ambiguity no doubt favors the insurance company. If the insurer failed to disclose the bit of info about waiving the Guaranteed issue LTD based on EOI submitted for option 1 STD coverage, the applicant usually has the possibility for a favorable outcome.

It will be expensive to hire an attorney for this kind of specialized litigation. SOP for insurance companies is/was to cave when they receive a single letter from an attorney, anything to avoid legal fees and court cost. But those decisions by insurance co's also take into consideration cost of legal fees versus paying one denied medical claim? or legal fees versus possibility of paying life long LTD benefits.

I recommend contacting the insurance commissioner's office. I feel confident there should be a notice that the Guaranteed issue LTD is waived with selection of option 1 STD, IMO.

At minimum a notice that the EOI required for option 1 STD will be used to determine eligibility for LTD policy, waiving/revoking the offer of Guaranteed Issue LTD during enrollment within 30 days of hire, etc.

Best of luck to you, I hope you have a favorable outcome. Also, keep us informed of your progress, it could be helpful for others who use the forums. BTW, satchmo and I know what it means to miss new orleans.
Reply With Quote
Reply

Thread Tools
Display Modes

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is Off
HTML code is Off

Forum Jump


All times are GMT -6. The time now is 06:03 AM.