Long Term Disability Denied - Any Suggestions???

Chuckles0504

Hi,

I am caregiver to my husband who was diagnosed with Stage IV Base of Tongue Cancer.  He was treated with 8 Erbitux treatments and 40 radiation treatments.  Treatment ended in April of  2012.  Docs thought they had it taken care of but unfortunately cancer continued to grow from the center of his tongue to the right side.  He had to have a 19 hour surgery on December 17, 2012 to remove the entire base of tongue, part of his larnyx, and his hyoid bone.  A radical neck dissection was done and we were told between 70-80 lymph nodes were  removed.

Anyways, to get to the issue at hand, he was on short term disability from the insurance company his work deals with.  I had been in contact with the girl from the insurance company several  times and she told me that when his short term disability ran out (March 25th) that it would automatically roll over into his long term disability.  I received a call from the girl in charge of long term disability and she said they were not even going to put the claim through because it would definitely be denied.  When I asked her why, she said because his cancer was a pre-existing condition because he had had cancer last year.   Yes, indeed he had cancer last year, but it never went away.  Basically, she said there is nothing I can do.  Has anyone dealt with anything like this bs from their insurance company?  I am at a loss how to proceed.

I spoke with his employer and they said they would look into it .  It has been three weeks and I have heard nothing from them or do they return my calls or email.  I feel there must be a way to fight this.  Does anyone have any ideas?  We should be okay for a couple of months but after that I don't think we could even pay the utilities on my sorry salary!!  Any insight would be greatly appreciated!!!

alligatorpointer

you may need legal assistance

From what others have posted, it seems to be the norm for disability claims to be denied the first time they are submitted.  But since you were told by the person in charge of long term disability that they were not even going to put the claim through because it would definitely be denied, you are not even being given the opportunity to appeal a denial.  The claim must be submitted before it can be denied, after which you can pursue the appeals process.  I do not have any first hand experience with this so I am hoping that other forum members will post whatever insight they may have to offer.  I have heard from various sources that the appeals process goes smoother when a lawyer who specializes in disability claims is used to navigate through the bureacracy.  It seems logical that your husband would qualify for long-term disability under the circumstances that you describe.  I hope you are able to find someone willing to handle this disability claim for you because you need to be able to focus on your role as caregiver.

Tim6003

alligatorpointer said:

you may need legal assistance

From what others have posted, it seems to be the norm for disability claims to be denied the first time they are submitted.  But since you were told by the person in charge of long term disability that they were not even going to put the claim through because it would definitely be denied, you are not even being given the opportunity to appeal a denial.  The claim must be submitted before it can be denied, after which you can pursue the appeals process.  I do not have any first hand experience with this so I am hoping that other forum members will post whatever insight they may have to offer.  I have heard from various sources that the appeals process goes smoother when a lawyer who specializes in disability claims is used to navigate through the bureacracy.  It seems logical that your husband would qualify for long-term disability under the circumstances that you describe.  I hope you are able to find someone willing to handle this disability claim for you because you need to be able to focus on your role as caregiver.

What???

Okay, now I've heard it all.  So if I understand correclty, your husband via his work had/has group insurance, which includes long term, short term disability.  Am I correct?

 

So he gets a dx of cancer, short term kicks in, correct?  So then his cancer "comes back" so to speak is the thinking of the insurer, so it's pre-existing????  Now as to my thought, even "if" the cancer did go away, if he has a recurrence, it still can't be considered pre-existing...that's just crazy.  And if indeed the National Cancer Institute declares a person is "not" cancer free until after 5 years...what the heck are they thinking!!

This sounds to me like an insurer just tyring to see if they can delay or not pay...I hate to say that bc I am not the normal "insurers are bad companies" type person, but jeez...

So first, tell them you have a right to a denial (which means they need ot submit the claim) or send you a letter stating why they are NOT going to submit it, then go get legal counsel...man that's just crazy.

Sorry you have to go thru that...I'm not legal or insurance guru..but stuff like that just bothers me.

Best,

Tim

phrannie51

Since this is long term disability

from the company he works for, I think there's a possibility that just a letter from an attorney threatening to sue might be all that you need.  It's not like governement disability.....where there are 20,000 pages of laws and ways to get out of paying for a legit claim.  He got cancer that's why he took is short term disability....and this is a continuing of that same disease.  Maybe they're trying to play with a tiny loophole because the tumor isn't in the exact same place....I'm sure they're hoping you'll just go away...don't fullfill their hopes!!

You also might skip calling his workplace HR office and simply walk in....make them talk to you.  They certainly have the ability to help you out, and the fact they're playing so hands off on this is deplorable.  Is this a union job?  The union might also help him out.

p

phrannie51

Tim6003 said:

What???

Okay, now I've heard it all.  So if I understand correclty, your husband via his work had/has group insurance, which includes long term, short term disability.  Am I correct?

 

So he gets a dx of cancer, short term kicks in, correct?  So then his cancer "comes back" so to speak is the thinking of the insurer, so it's pre-existing????  Now as to my thought, even "if" the cancer did go away, if he has a recurrence, it still can't be considered pre-existing...that's just crazy.  And if indeed the National Cancer Institute declares a person is "not" cancer free until after 5 years...what the heck are they thinking!!

This sounds to me like an insurer just tyring to see if they can delay or not pay...I hate to say that bc I am not the normal "insurers are bad companies" type person, but jeez...

So first, tell them you have a right to a denial (which means they need ot submit the claim) or send you a letter stating why they are NOT going to submit it, then go get legal counsel...man that's just crazy.

Sorry you have to go thru that...I'm not legal or insurance guru..but stuff like that just bothers me.

Best,

Tim

You hit right on the head, Tim....

We have much of the same setup here, as the poster's....When I got sick, I automatically got on short term disability, it would run for 6 months....IF I could not come back to work at the end of that six months it would automatically become long term disability.  OR, if I'd come back to work for at least 2 weeks, and something else came up, or I had a reoccurance, I could go right back on short term for another 6 months which again, would automatically kick into long term if I couldn't come back after 6 months.  This company is playing games, and I agree they NEED to submit that claim and give these folks a chance at legitament denial and possibility of appeal.

p 

Duggie88

Chuckles

I am a Trustee on a health and welfare fund and I agree, appeal their decision. Now keep in mind there is some difference in a Fund and Insurance so I can only speak on a Fund. My quick comparison of the two is, a Fund is a nonprofit group which in my view was set up to provide health care for union members at a reasonable cost to the employer. Insurance companies can’t touch our coverage at the same cost because they are in business to make money.

I sit in on appeals and we reverse decisions all the time based on individual circumstances. In most cases the person appealing doesn’t use an attorney but then again I haven’t a clue how the appeals environment would be like in your situation ours is very laid back and like I said we are here for our members.  In our appeals the lawyers learn about the case the same time I do which means they advise us of any laws pertaining to the case along with the Funds rules but in your case it would be the Insurer’s rules. I am not familiar with long term disability because our Fund only provides short term disability for six months with a ten week extension.

All that being said if I were in your shoes I would request a Summary of Benefits and Coverage (SBC) or the Summary Plan Description or whatever your insurance provider might call the description of the plan you are in. At the same time ask for an appeal form and what their process is to appeal . I would sit back and take a deep breath and read about the coverage and seek a lawyer who will initially consult with you for free. Thinking about it I would consider a lawyer for the simple reason Insurance Companies are some of the richest companies in the world for a few reasons but mostly because they take a lot of money in and put out the least amount as possible.

I know…..I know, with all this talk on insurance companies and lawyers now I have a headache also. Time for some coffee with a Jameson Oxycodone chaser.

Enjoy today………………..it’s practice for tomorrow.

      Jeff

staceya

Duggie88 said:

Chuckles

I am a Trustee on a health and welfare fund and I agree, appeal their decision. Now keep in mind there is some difference in a Fund and Insurance so I can only speak on a Fund. My quick comparison of the two is, a Fund is a nonprofit group which in my view was set up to provide health care for union members at a reasonable cost to the employer. Insurance companies can’t touch our coverage at the same cost because they are in business to make money.

I sit in on appeals and we reverse decisions all the time based on individual circumstances. In most cases the person appealing doesn’t use an attorney but then again I haven’t a clue how the appeals environment would be like in your situation ours is very laid back and like I said we are here for our members.  In our appeals the lawyers learn about the case the same time I do which means they advise us of any laws pertaining to the case along with the Funds rules but in your case it would be the Insurer’s rules. I am not familiar with long term disability because our Fund only provides short term disability for six months with a ten week extension.

All that being said if I were in your shoes I would request a Summary of Benefits and Coverage (SBC) or the Summary Plan Description or whatever your insurance provider might call the description of the plan you are in. At the same time ask for an appeal form and what their process is to appeal . I would sit back and take a deep breath and read about the coverage and seek a lawyer who will initially consult with you for free. Thinking about it I would consider a lawyer for the simple reason Insurance Companies are some of the richest companies in the world for a few reasons but mostly because they take a lot of money in and put out the least amount as possible.

I know…..I know, with all this talk on insurance companies and lawyers now I have a headache also. Time for some coffee with a Jameson Oxycodone chaser.

Enjoy today………………..it’s practice for tomorrow.

      Jeff

Legal Assistance

Just recently listened to a radio show about disability on NPR

There were many episodes but the one I heard was on helping people who had been denied, get disability benefits. The title is Expanded Definition Of Disability Created Million Dollar Opportunity For Lawyers, but I thought it was helpful from the patient perspective.

 

 

 

 

Chuckles0504

Thanks

Thanks to all who responded.  I plan to start aggressively acting on this situation.  I will keep you all updated on what happens.  The call where the gal stated they weren't even going to submit the claim just caught me so off guard!  Thanks again everyone!

rteicher

Long Term Disability Denial

Hello,

 

I would like to put you in touch with attorney Glenn Kantor. He is an attorney that speciliazes in long term disability denials. 

www.kantorlaw.net

 

Please send me and email so that I can put you in touch!

 

Take Care,

Rachel

rteicher@kantorlaw.net