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Old 03-10-2009, 11:44 PM   #1
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Long Term Disability Benefits Denied

Hi All,

I am new to this internet environment. But not new to pain and suffering…

I had a long and complicated spinal fusion L3-S1 with screws, rods and plates, right after the surgery; I lost feelings to my left foot… Now, I have more back and lower back and buttocks pain coupled with numbness on both legs and at buttocks, as well as foot drop…. My Long Term Disability Benefits Company acknowledges that I am permanently disabled from my own profession…

Two years after my surgery, both of my doctors (Ortho-surgeon and Neurosurgeon) evaluated and determined that I have a permanent nerve damage, which limits my daily functions. Both doctors independently performed Functionality Evaluation and determine that I could NOT even perform sedentary work… I forwarded these findings to LTD Benefits Administrator for considering me for permanent LTD, to my surprise they want me to try NEUROSTIMULATION IMPLANT… After doing a long search and talking to people (through Medtronic’s Ambassador program) who had the implant, and through pain specialist who would do the trail, indicated that it would only help my LEG pain not my back or lower and buttock pain, it MAY also help with sensitivity on my toes, but will not help FOOT DROP…
Known all these drawbacks and with little benefit, I really don’t want to go through another surgery… How could I explain these to LTD Benefits Administrator Company? Can they make me have this implant? They are not paying for this procedure, I have my own health insurance (through my spouse)… If I don’t do this, can they come back and deny my benefits due to refusing a treatment? They have evaluation statements from 2 surgeons… I am permanently disabled… What more could I provide to them?

This is the company told me to LIE to State Agency to get my car modified at state expanse… (I was to tell the state rehab agency, I needed this to go to work), of course I would not do that... I paid it out-of-my-pocket (it was over $2500 includes training). I don’t trust anyone who tells me to lie period…

I even ask (LTD Benefits Administrators), to get me evaluated by their own doctors, and they indicated that they have enough information from my surgeons…

I consulted couple attorneys, they are all SUE crazy, they want to sue the surgeons, and they will take my case to ERISA (but it may cost me anywhere from $20-30K)… Lawyers require $10K in escrow account, before they do anything… I know that nerve damage was done during the surgery or during my recovery period. Doctors did their best; no doctor knowingly will hurt their patients… I can’t sue anyone; it is not an option…

I really don’t know what to do with the LTD Benefits Plan Administrators request? I have two surgeons certifying that I am disabled, I am on heavy duty pain killers, and it already damaged my liver… I can’t honestly go to work, if my LTD Benefits is terminated, I really don’t know what to do… I already filed for SSD Benefits, it is at hearing stages, and it may take another 5-6 months before anything…

Any input greatly appreciated and NEEDED….

Thanks in avance.

 
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Old 03-11-2009, 08:39 AM   #2
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Re: Long Term Disability Benefits Denied

Welcome to the boards....You will find many here who have a wide variety of experiences and many can offer a wide array of support. I will try to help as best I can.

As you probably know, insurance companies do all they can to keep from having to pay a claim. They all want us to pay premiums, but they don't want to pay a claim. The reason they don't want you to see one of their Docs is because they know they have more than enough documentation already and sending you to a Doc would only cost them money. One Doc is enough to document disability....You have two...And they are specialists at that.

I'm not a LTD expert by any means, but do have a lot of experience with it....I worked for a big fortune 10 company and went on STD, then LTD, and also applied for SSD, which took about 1.5 years to receive.

Is this LTD administrator at the insurance company or your company? Have they come straight out and said that you need this implant or they'll reject the claim, or have they simply recommended it?

I doubt seriously that they can make you get it in order to approve the claim. I'm guessing that they have strongly recommended it....Which is their way of trying to get you to do everything that is in their best interests, not necessarily yours.

Any time one is in disability, documentation is the key. I would visit both docs and ask them to write a short note to the administrator saying that the implant will not be successful. Personally, I think you could just say "no" and they'd have to pay the claim, but this type of letter should seal the deal for you and make you feel better about everything.

Stay strong....They will have to pay....As long as you do everything correctly.

Best of luck to you.

Regards,

Ex

 
Old 03-11-2009, 12:17 PM   #3
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Re: Long Term Disability Benefits Denied

Quote:
Originally Posted by Executor View Post
Welcome to the boards....You will find many here who have a wide variety of experiences and many can offer a wide array of support. I will try to help as best I can.

As you probably know, insurance companies do all they can to keep from having to pay a claim. They all want us to pay premiums, but they don't want to pay a claim. The reason they don't want you to see one of their Docs is because they know they have more than enough documentation already and sending you to a Doc would only cost them money. One Doc is enough to document disability....You have two...And they are specialists at that.

I'm not a LTD expert by any means, but do have a lot of experience with it....I worked for a big fortune 10 company and went on STD, then LTD, and also applied for SSD, which took about 1.5 years to receive.

Is this LTD administrator at the insurance company or your company? Have they come straight out and said that you need this implant or they'll reject the claim, or have they simply recommended it?

I doubt seriously that they can make you get it in order to approve the claim. I'm guessing that they have strongly recommended it....Which is their way of trying to get you to do everything that is in their best interests, not necessarily yours.

Any time one is in disability, documentation is the key. I would visit both docs and ask them to write a short note to the administrator saying that the implant will not be successful. Personally, I think you could just say "no" and they'd have to pay the claim, but this type of letter should seal the deal for you and make you feel better about everything.

Stay strong....They will have to pay....As long as you do everything correctly.

Best of luck to you.

Regards,

Ex
Hi Ex,

LTD administrator at the insurance company ... They initially denied my claim (not enough evidence to change their mind), I sent them 6 pages of letter and new evidence my office visit reports, my MRI and CT Scan reports and 2 separate evaluation reports from my surgeons, with both surgeons notes and evaluations indicating I am disabled, can’t even perform sedentary work. I thought letters and notes were enough to seal the deal. But I was wrong, it was my case manager VERBALLY indicated, they will wait until the results of implant before they rule on my case...

I have been seen pain management specialist. As with all specialists, they all recommend their own product; they get kick-backs from manufacturers. Pain Specialist Doc himself indicated, implant MAY help, he just wants me to try it for 3-5 days, I am willing to try anything to get-rid-off the pain, but NOT when someone mandates it. Specialists make their money by performing procedures on you… Like neurosurgeon recommends myelogram, or injections, it takes them 30 minutes or less and charges several thousands dollars. Everyone is out there to make a buck, at any expense.

Is it possible to fight LTD Administrator Company with out lawyers…?

Last edited by Fused2006; 03-11-2009 at 12:19 PM.

 
Old 03-11-2009, 08:56 PM   #4
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Re: Long Term Disability Benefits Denied

Quote:
Originally Posted by Fused2006 View Post

LTD administrator at the insurance company ... They initially denied my claim (not enough evidence to change their mind), I sent them 6 pages of letter and new evidence my office visit reports, my MRI and CT Scan reports and 2 separate evaluation reports from my surgeons, with both surgeons notes and evaluations indicating I am disabled, can’t even perform sedentary work. I thought letters and notes were enough to seal the deal.
I am very surprised that the LTD administrator would rule against two Docs...And specialists at that. I'm even more shocked that some non medical person can tell you what to try next.


Quote:
It was my case manager VERBALLY indicated, they will wait until the results of implant before they rule on my case...
I thought they already ruled?? Have you appealed or something? What if you don't elect to get the implant....Have they said?


I will comment more once you can clarify this for me.

Regards,

Ex

 
Old 03-11-2009, 11:48 PM   #5
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Re: Long Term Disability Benefits Denied

I am disabled due to some similar conditions of my back but I also have issues with my neck. I worked in HR with an emphasis in employee benefits for 20+ years prior to my disability. I was on LTD for 2 years. Many plans now have a limitation in place for spine disorders. They limit the LTD benefit to 24 for months if you are disabled due to disease or disorders of the spine joints and muscles. If your plan does not have this limitation, you should be able to pursue a permanent disability claim.

Some of this is a bit confusing. You state that your LTD company has indicated you are disabled under the own occ definition but they have denied your claim? If they have admitted to you in writing that you are disabled, what grounds are they using to deny your claim? How long have you been out of work? Have you drawn any LTD benefits yet? Who is your LTD company?

No they cannot force you to have this implant done nor can they deny your claim if you do not have it done. They can recommend it but not deny a claim should you not have this done. There are no guarantees that this implant will work or not work. I also discussed the implant at length with my pain specialist and the Medtronic reps but I was uncomfortable with the process and declined it. There is a trial period before the implant is done permanently. My doc told me if there isn't at least a 40% improvement in my condition during that trial period, they do not do the implant.

To be safe as Ex stated, have your doctor write a letter to the LTD company stating why this implant would not be beneficial. The LTD company takes your medical records before a medical review board. There is a list of criteria just like social security that has to be satisfied to deem one disabled. Since you have 2 separate doc reports, this should be sufficient for the LTD company to rule on your case.

Have you gone to your HR department with the concerns about the LTD company? The HR role is to assist you with problems you are incurring due to the LTD Administrators requests.

With a little more information, I think we may be able to narrow down where the problem is coming from. There may just be some communication break down that can be resolved. I don't think you are at the "lawsuit" level (yet).

 
Old 03-12-2009, 09:41 PM   #6
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Re: Long Term Disability Benefits Denied

Quote:
Originally Posted by hugg724 View Post
I am disabled due to some similar conditions of my back but I also have issues with my neck. I worked in HR with an emphasis in employee benefits for 20+ years prior to my disability. I was on LTD for 2 years. Many plans now have a limitation in place for spine disorders. They limit the LTD benefit to 24 for months if you are disabled due to disease or disorders of the spine joints and muscles. If your plan does not have this limitation, you should be able to pursue a permanent disability claim.

Some of this is a bit confusing. You state that your LTD company has indicated you are disabled under the own occ definition but they have denied your claim? If they have admitted to you in writing that you are disabled, what grounds are they using to deny your claim? How long have you been out of work? Have you drawn any LTD benefits yet? Who is your LTD company?

No they cannot force you to have this implant done nor can they deny your claim if you do not have it done. They can recommend it but not deny a claim should you not have this done. There are no guarantees that this implant will work or not work. I also discussed the implant at length with my pain specialist and the Medtronic reps but I was uncomfortable with the process and declined it. There is a trial period before the implant is done permanently. My doc told me if there isn't at least a 40% improvement in my condition during that trial period, they do not do the implant.

To be safe as Ex stated, have your doctor write a letter to the LTD company stating why this implant would not be beneficial. The LTD company takes your medical records before a medical review board. There is a list of criteria just like social security that has to be satisfied to deem one disabled. Since you have 2 separate doc reports, this should be sufficient for the LTD company to rule on your case.

Have you gone to your HR department with the concerns about the LTD company? The HR role is to assist you with problems you are incurring due to the LTD Administrators requests.

With a little more information, I think we may be able to narrow down where the problem is coming from. There may just be some communication break down that can be resolved. I don't think you are at the "lawsuit" level (yet).
An excellent post....Lots of very helpful information.

Regards,

Ex

 
Old 03-13-2009, 01:14 AM   #7
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Re: Long Term Disability Benefits Denied

I'm a little confused about the LTD and SS. I worked for the State and in order to be granted early retirement based on being disabled, I needed two doctors to state I am permanently disabled. So that was granted and I get a small pension. I applied for SS Disability two years ago this March. I was denied twice. The State says I am permantly disabled but Social Security says I am able to sit and stand long enough to work. You would think a Federal Agency would agree with the State agency. Since my retirement is based on being disabled, I could not work if I wanted to. I do want to but physically would not make it. So, waiting for a court date. Sent that paperwork back July 2008. Well, atty. did. I think they all have an unwritten rule to deny the first time no matter what.

 
Old 03-13-2009, 08:21 PM   #8
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Re: Long Term Disability Benefits Denied

Quote:
Originally Posted by hessie28 View Post

I'm a little confused about the LTD and SS.
LTD is almost always a private policy or special policy offered through your employer....Or, one can purchase LTD from an insurance agent...Just like you can purchase life insurance, for example.

With LTD, the particular insurance company has their own set of criteria to determine if one is disabled. For example, I had LTD through my employer, and the criteria was "the inability to perform my job or any other job that I was suitably trained and educated for."

Once I left my job, I went on STD, then LTD, which turned into permanent disability. Like your situation, my LTD was granted fairly easily by following the set of criteria required by the policy. I get a check every month from my LTD policy based on my salary when I left my job.

SS disability is a totally different animal. It is funded by the Federal Gov't. As you know from reading posts on this board, the "stories" of such are all over the spectrum. They pretty much deny everyone at first as a way to limit claims and to find out who is serious or not. A select few are awarded SSD quickly, but there seems to be no rhyme or reason for it...Just luck, honestly.

SSD has their own criteria and they will do everything they can to keep from paying. Once someone is granted SSD, it's pretty much a payment for life, so that is why they are very tough. Additionally, it's the "government" and thus, it's half backwards. Unfortunately, many have died waiting for their SSD to be approved.

For many LTD policies, they have a rider, or contingency in the policy that if approved for LTD benefits, the policy requires one to file for SSD....Mine did....Which again, is very common....It's the "standard" actually.

And if one is eventually awarded SSD, whatever amt one is awarded (from SSD) is subtracted from the LTD. For example purposes, say one is awarded $2K per month on one's LTD policy. You then apply for SSD as part of the LTD policy requirements. Eventually, you are awarded $1K per month by SSD. The amount you are awarded from SSD, or $1K, is subtracted from your LTD of $2K. You would then get $1K from SSD and $1K from LTD. Your net amt doesn't change, but how you get it does.

Hope this answers some of your questions.

Regards,

Ex

 
Old 04-10-2009, 02:49 AM   #9
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Re: Long Term Disability Benefits Denied

Very intresting post. Within your benefit/policy description there is probably wording such as insurer can require employee to seek reasonable rehabilitative treatment ... I doubt (legally) that includes a surgical implant that requires you to have anesthesia and sign a surgical release to a procedure that prevents you from future MRIs and carries a sampling of these warnings: "Sources of strong electromagnetic interference (eg, defibrillation (hello! What if you have a heart attack and need defrib) diathermy, electrocautery, MRI(what if you need continuous MRI monitoring?), RF ablation, and therapeutic ultrasound) can interact with the neurostimulation system, resulting in serious patient injury or death. These and other sources of EMI can also result in system damage, operational changes to the neurostimulator or unexpected changes in stimulation."

Sounds like they are stiff- arming you and I would either seek legal opinion, or get the facts on the procedure and write a documenting letter to them as such, stating the medical and other reasons for not doing along with your treating doctors opinion.


(sorry for formating/sp, typed on BB.

Last edited by PNo; 04-10-2009 at 03:33 AM.

 
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