LTD appeal

[lstrl]

I just got my long term disability denial letter in the mail today. They state that it is a pre-existing condition and that two doctors treated me in the year before I took out the policy for numbness and weakness in the lower extremities. Actually, the first dr didn't have anything to do with lower extremities because I saw him for arm numbness (no treatment for that either though). I told the second I appeared to have foot drop in in the left (not both extremities), but not once did anyone treat me. The definition of treatment, as according to the policy is:
1) medical exams, tests, attendance, or observation; and
2) use of drugs, medicines, medical services, supplies, or equipment

When I go back to my jr high grammar lesson, I learned that the "and" means that both statements must apply in order for them to use that against me. Yes, I saw two drs that ordered tests. No, they did not give me any drugs, supplies, or equipment, and I was not sent for any kind of medical services. The LTD policy paperwork I printed from my employer states that you're still eligible with a pre-existing condition if you have seen a dr for the condition but haven't received treatment for that condition for 365 days before the policy started. I was never given any kind of treatment until I was diagnosed, and that is after my policy started, so it doesn't matter.

I'm definitely appealing this because I think they're using a play on words to deny me, and I believe that what the policy states means that I'm legally eligible (and fyi, the insurance company conveniently left out the part of the policy that states no treatment for the past year means you're eligible, but I've got it in my possession).

I have absolutely no experience handling stuff like this, but I am a very intelligent person and I can write a very good paper. I figure I can highlight the terms and definitions to support my case and send those along with a detailed paper stating why I should be approved. Honestly though, I really don't know what I'm up against (but my head tells me this should totally go my way). Should I try to do this on my own and see what happens, or would I be better off contacting an attorney now? I'd hate to pay someone a bunch of the money I get if I win, but I also want to make sure I do win, and I'm out nothing if I lose.

[MarkLavelle]

You might eventually have to resort to a lawyer, but I don't see how it could hurt to try on your own first. It does sound like they're just trying to scare you off.

On the other hand, it might be worth a few bucks (not a contingency) to ask a lawyer about the best approach...

[Thinkimjob]

I don't know. Depends on what the meaning of "is" is.
D'you have n0 won, no pay lawyers in the US? Mind you, they win, you pay.

[Andy75]

You may see if you could get a consultation with a lawyer who specializes in ERISA law. In the long run, it may be worth the money because the LTD company may use various tactics to intimidate you.

Also, you probably already have it but just in case you don't, get a copy of your medical records and review them. There may be some errors in them.

Best of luck

[mjan]

Oh Istrl, I can feel for you. I am in the middle of appealing a decision of denial for continued benefits from LTD.

Now originally, I did receive LTD without even asking. Funny, I was under the care of a MS specialists from 2004-2008 where that MS neuro concluded that I did not have MS. Ironically, his denial lead to several OTHER disorders/diseases that may have been missed.

Now I also tried to fight having my LTD cut off early. So believe me they do not care. I also thought I did a bang up job with my own appeal. NOT!! LOL

So I would HIGHLY recommend consulting with an Attorney who does employee-employer relations issues. They can tell you if you even have a case.

I did. Won a partial appeal from what they owed me for hte rest of the 1st 2 years. I am now fighting the rest of the benefit, the last 2 years. The ONLY reason I can, is that I came in late at age 61 so I am entitled to another two years of LTD benefit. Its 20K that they still owe me so to me it is worth is. I already have SSDI and they know it.

They did determine with the partial award, that I can no longer perform MY job, but I could still work..so to me it is worth the fight.

Please do not try this alone. They just don't care. They do listen to lawyers as this can eventually end up in court and all want to avoid that cost.

Let me know what happens.. best to you~

Jan

[onlyairfare]

I'm so sorry you have to go through this. Sometimes the battles with the insurance company can seem worse than the MS.

I too had a disability claim denied. It was an STD claim because of a complicated pregnancy, nothing to do with MS, but it was denied anyway on the basis that I had not disclosed MS as a pre-existing condition in my application.

I had a friend who was a licensed attorney though he actually worked as an art dealer. He referred me to a classmate of his from law school who specialized in health insurance law. That lawyer was able to get the insurance company to pay up. I did pay him some hourly legal fees of around $500 total for a couple letters and phone calls, but the insurance company owed me about $10,000 - and they paid it.

I had battled the insurance company myself for about 6 months before retaining the attorney, who resolved the issue in just a few weeks, so the $500 in legal fees was money well spent. Another friend commented to me "Gee, a lawyer is better than a .357 Magnum in your situation!"

I feel for you lstrl, and I hope you can get a fair decision in your favor.

[lstrl]

Thanks for all of the advice. I'm not giving up so easily. I've been trying to get ahold of this lady I'm pretty sure never works since Monday (about to leave my 3rd daily message and I'm about to tell her I'm not going to quit until she does her job for once) to get a copy of my medical records. I also sent a message to an ERISA attorney who was recommended by a good attorney I used last year, so hopefully I'll hear from him soon.

As easy as I thought this looked in the beginning, I've decided I don't want to take the chance on doing this alone. It's worth paying some money if I can get a guaranteed win. After all, it's not like I pay anything if I lose. I also don't want to wait months. If I could win this soon, I might not have to take a job I'll be interviewing for that I absolutely want nothing to do with but I feel obligated since my parents have to pay my expenses if I don't get an income very soon. Hopefully something will start going my way in the very near future.

[mjan]

First of all, the attorney will usually consult without a charge. I also asked if they ever worked with this insurance company contracted with my employer and they had and seem to know the loopholes they use to get out of paying.

Then I paid 2400 with a 350 feel to review all my records. I borrowed the money. They also offered the contingency plan where they get a third I think but up to a certain amount. I figured they would get MORE of my $$ due than if I paid the flat fee. Glad I did it that way.

Now good news is that the insurance company (Cigna) usually respond with their answer within 30 days of receiving everything submitted and reviewing the records. I thought that was fast.

Keep us posted.

Jan