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Short term disability

GregStahl
Posts: 188
Joined: Apr 2010

Ruby just found out that she doesnt qualify for short term disability. The time off from work for (by their information) "standard" bilateral mastectomy is 2 weeks. She has to be off until the 12th because she still has drains in and even though the Dr is removing those Fri, he wont release her until the 8th to make sure those heal. That is not good enough as the insurance companies information states 14 days to return to work.

Bad enough we have $3500+ in med bills already, AC went out ($1800) and now her X has decided that he is going to take a few months off and NOT pay child support.....AGAIN!!!!.

We just got out of financial trouble

When it rains!!!!!!!!!!!

New Flower
Posts: 3914
Joined: Aug 2009

nothing new - just another insurance company concerning about its bottom line.Please talk to your doctor - breast surgeon. Ask for for letter or evaluation describing your wife medical conditions, drains and other complications. Plus occupation is an important factor. You need to appeal insurance decision. They will not deny if your doctor provides written supporting document.
Good luck

mimivac's picture
mimivac
Posts: 2147
Joined: Dec 2008

Don't accept the insurance company decision without appealing. Often a doctor can write a letter to get things moving. I'm sorry for all the bad luck you are dealing with financially. You're right, things seem to happen all at once. Do you live in a state with public disability benefits (New York, New Jersey, California, Hawaii, Rhode Island, Puerto Rico)? Good luck.

Mimi

New Flower
Posts: 3914
Joined: Aug 2009

If you can get more than one letter from all of your doctors, including primary care physician it will give your appeal more weigh. Ask all of your doctors for letters. She probably does not have range of motion , so physical therapist could be helpful too. Please let us know.
Good luck

GregStahl
Posts: 188
Joined: Apr 2010

We have been fighting this and fighting and fighting.....She works for a hospital and they are self insured....she is an insurance biller (ironic?). Her having the drains is not a medical reason to stay away from work even though her employer wont let her return while she has those in (health issues if the open and spill).
We called the surgeons nurse and we will see if he will release her to go back monday after the drains are out, but she still has to meet the hospitals guide lines.

Do they make this intentionally hard? Once she was Dx with cancer, United Health care refused to pay claims because this was a "pre-existing condition" because she didnt have insurance with THEM for more than 1 calander year. She had my insurance thru Aetna for 10 years, but at the time UHC siad that didnt matter. She went thru UHC due to cost to me if covered under IBMs plan which was $350 a month as opposed to $160 under UHC.

So now all those claims that got held or refused have sent bills, one going to collections in 15 days. UHC told us to pay the bills and fill out the paperwork and send to them and they will cut us a check in 60 to 90 days.
Aint got $22K, $2k, $2, to cut a check.

Sorry, just so damn p*ssed off, we need that short term $$$$.

New Flower
Posts: 3914
Joined: Aug 2009

I have been dealing with medical claims for two years now since July of 2008. Non-stop call and fight. Your wife medical oncologist also can help. It would be nice if you can get doc who are not related to your hospital. Do not forget in your formal appeal that her diagnosis not "mastectomy" it is breast cancer. Good luck. I am sure you will win, just take a stand.

sweetvickid's picture
sweetvickid
Posts: 436
Joined: Nov 2009

If she had insurance thru another carrier before UHC they can't claim pre-existing condition.

GregStahl
Posts: 188
Joined: Apr 2010

stopped payments until we could prove coverage....which we did so they held payments up anyway.

Deb1969's picture
Deb1969
Posts: 165
Joined: Aug 2009

I always thought unless there was a lapse in coverage, it cant be considered pre existing.

GregStahl
Posts: 188
Joined: Apr 2010

people just take what they are told and pay? How many dont get treatment because they cant "afford" it because the insurance says they dont cover?

Its all too easy to blame the insurance companies, but its Drs, hospitals, labs, pharmacutical Co, its the whole thing.

I am about 9 kinds of ready to give up and we are just starting this. Her Insurance doesnt cover rads (if the hospital she works for doesnt offer the service they dont cover), so hope she doesnt need it.....if she does, just another fight.

New Flower
Posts: 3914
Joined: Aug 2009

the whole system is broken. Please do not give up just be persistent. They want you to give up for sure. This is her life- recovery is very important.

Kat11's picture
Kat11
Posts: 1931
Joined: May 2009

The way I see it. Do what ever you need to do to get her the treatment she needs. I know the debt that this illiness will cause. Worry about the bills later. I think there is places you can go for help with this. Call the ACS. It just should not be the fight of your life. Anyone should be able to get the treatment they need.

GregStahl
Posts: 188
Joined: Apr 2010

According to Tom in India, if Ruby has to have another bilateral mastectomy in the next 90 days, she could qualify for STD payments.
FER REAL PEOPLE, THAT IS WHAT "TOM" TOLD ME

MerleBee's picture
MerleBee
Posts: 49
Joined: May 2010

So the good news is that "Tom" reminded you that your wife apparently has at least FOUR breasts...that's good news because you could probably get some serious dollars for the story from the Nat'l Enquirer...It is UNBELIEVABLE! When my insurance company informed me that they would not cover my wig (cranial prosthesis)the gal told me that I would be covered if i required counseling because i had to go to work with no hair...ahhhhh!
Greg I am so very sorry that you both have to deal with this at a time when you should be totally focused on fighting the beast...not the health care/insurance system! I will be praying for a viable solution to this for you both!
Merle

roseann4
Posts: 994
Joined: Sep 2009

From my experience, there are standard expected recovery times for specific conditions. However if your doctor has reasons why your situation is different, you can appeal that and get coverage. For example, normally a c-section delivery is 8 weeks but my niece suffered an infection and was paid for 12 weeks. Don't assume that you can't appeal. Call your doctor, explain the situation and appeal the decision. You may qualify for additional benefits. Good luck.

Roseann

New Flower
Posts: 3914
Joined: Aug 2009

the standard recovery time for mastectomy is 5 weeks. Some people have drains for 10-12 days even without complications.I hope your doctors will help your wife.

Hubby's picture
Hubby
Posts: 325
Joined: Apr 2010

Sorry you have to go through this. Financial stress on top of all this health stress just s*cks. Going through some of it too, not from my insurance, but just in general. Be persistant.

Bob

meena1's picture
meena1
Posts: 1005
Joined: Oct 2008

First, i was approved for 4 weeks off after my disability. However, i had a rough recovery and I was approved for an additional 4 weeks, so i had a total of 8 weeks off after my masectomy. I never heard of 2 weeks off, this is just crazy. definitely try appealing.

MyTurnNow's picture
MyTurnNow
Posts: 2694
Joined: Aug 2009

Greg, I don't have anything "new" to offer but wanted to reiterate what the others have said and that is to be persistent. Also, make this your task so you wife doesn't have to feel the stress. She really needs to concentrate on her health and get through this journey with as little stress as possible. I do know how stressful it can be when there are money issues. As hard as it is, I would continue the fight but until there is resolution regarding disability, etc., just let these creditors know that their bills will not be paid until the issues are resolved. They can notate their records as such. Good luck and I'm hoping for a positive response for all parties involved. Keep us posted.

GregStahl
Posts: 188
Joined: Apr 2010

We are fighting this as best we can....have the VP of HR at her office involved and hopefully will get some answers. I just cant believe some of the things we have been told. THose not familiar with insurnce could lose big if they believe what they hear.

If we had kept her under my insurance, we wouldnt have most of these issues.

Thanks for letting me vent all.

greyhoundluvr's picture
greyhoundluvr
Posts: 402
Joined: Apr 2010

I have to say that I am absolutely shocked. I hate to admit it but I used to work for UHC and have to agree with everyone else - I can't believe that they are being so difficult about this but if I get the gist of things, they are administering the benefits of the self-insured hospital rather than one of their own plans. The plastic surgeon I go to always remembers that I am a nurse and always asks me if I work for one of the local hospitals (which I don't thank heavens) because they are self-insured and so difficult to deal with. And the disability piece is almost more shocking. While there are disability guidelines, they are just that - guidelines. If they are going to contradict the medical opinion of the doctor, it should be based upon facts that support that your wife is medically able to do her job (which her employer apparently says she is not able to do). It took me 4 weeks to get all of my drains out and I can't manage going into a hospital to work before that. Let alone saying that they will not cover her rads - I have never heard of such a thing. Hopefully, the HR folks at the hospital can get this mess straightened out but I think it would be fair to ask "Tom" for the medical qualifications of the person who is countering your MDs opinion (my guess is that there probably are not any). Like the others said, there is definitely a basis to appeal. The other option would be to see if the insurance commissioner in your state will address either of these issues (it varies from state to state). There is also the option of legal aide but I know how touchy that is when the insurer is self-insured through the company Ruby works for. I will keep all of my fingers and toes crossed that HR works this out for you quickly and you guys can get to on to just having to focus ongetting her better!

MOrtiz0810
Posts: 42
Joined: May 2010

So you mentioned that your spouse's employer is a "Self-Funded" Group? In many cases, those are the worst employers because they can "Customize" their Health Plan, to save themselves money. I'm not saying that all self-insured employers are horrible, but some of them can remove State Mandates from their Standard Insurance policy. For example, my Employer is a Self-insured company and the jerks decided to remove a Mandate that many states have in place, for Wig coverage, so while many other employers cover wigs for cancer patients, because it is a mandate in many states, my employer doesn't have to add it on to their policy. It really sucks how many of these large Corporations can remove and add benefits into their Health Insurance policies, as they see fit for them! I'm sorry you and your wife have to go through the nightmare of dealing with all of that mess.

The other issue is that most employers can buy into a short-term disability plan, which at least covers about 60% of the employee's salary. My employer did offer the short-term disability benefits and I have been able to take at least 12 weeks off because I had some minor complications from the reconstructive surgery. But, in all honesty, it was a tough fight getting approved for all of those weeks and I'm still fighting with them because the disability company needs the Medical notes every time I see the Surgeon, and of course, the surgeon's office is a bit slow with submitting the office notes. Just last week, I had a breakdown and I insisted on speaking with a Supervisor from the Disability Company, and they rushed the review and approval through.

It's bad enough we have to fight the Cancer, but to add to our burdens, we have to fight for our salaries and our Health Insurance!

I do hope things get better and I wish you and your wife all the best on this road to recovery :)

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