EVER FIGHT AN INSURANCE COMPANY??

Mary

As many of you know, my brother in law is fighting a life-threatening disease and the chances of him surviving, are slim. My sister has been off on Short Term Disability since June, since she's in no shape to work. She's worked for the same company for 32 years and has probably taken 5 sick days during the entire time she's worked there. She's gone in many times when she's sick (because that's what they expect) but realizes now that there is no way she can work, and has gone off on Short Term Disability.

Her boss signed off stating that my sister was emotionally distressed, crying and not able to work, her doctor has filled out the forms stating that he does not believe she's able to work, yet the stinking, rotten insurance company called my sister, told her that they think she can go back to work and that "there's ways you can handle this" and "we sympathize with you....we really do, but..." and are going to cut her off of the benefits. I'm fairly sure that they're wanting to do this NOW, before Long Term Disability kicks in in a couple of weeks.

Insurance companies are the lowest form of scum, IMO. They love to suck the premiums out of you every month, but hate like hell to actually pay when someone needs it, and will go to the ends of the earth to save themselves every penny possible and to maximize their profits. And if people get screwed along the way, oh well, too bad so sad.

Anyway, she's in no shape mentally or emotionally do deal with this crap, so she faxed them a letter authorizing me to act on her behalf. I've got a copy of the form her doctor filled out along with the letter they sent to her telling her she's getting cut off. Her doctor wrote her a referral to talk to a Psycologist, I'm going to be calling the woman from the insurance company to see on what grounds they're denying her a continuation of the benefits, I want her supervisors name and an address because I will most likely be talking to a lawyer.

This is one time where being raised as a Witness might come in handy. Since I've so many years experience with bugging people who say "No, go AWAY" and just ignoring that, I think that after a while, they just might re-think their position. I've got a fairly good idea as to how I'm going to proceed on this, but I just wanted to know if anyone else had any suggestions or experiences dealing with insurance companies.

OUTLAW

Get a lawyer..

..Nail the bastards..

................OUTLAW

purplesofa

Mary,

If anyone can get something done, I believe it's you!!!!

I have been in situations where I was not able to handle things and had someone like you to do it,

What a gem.

so, sorry you all are going through this.

purps

mkr32208

Hey don't talk about the free market insurance companies like that you might upset BTS or other of his ilk! After all the insurance companies are the best thing that ever happened to this country! Well except W. He was a little better for us but not much!

SnakesInTheTower

Mary...

I have some educational background (my first college degree is in medical office work) in dealing with insurance companies. Often, the initial denial is either a computer operating off of an algorithm or an overworked, underpaid clerk who often is on a bonus structure to deny claims. You have to get past that person/computer and beyond even the next level of people before you can get this overturned.

The person who called is merely a claims clerk following up on the paperwork that was sent. Operating off of what is essentially a script. Really, I am shocked you all got a phone call at all. Usually that is yet another letter.

My advice, for what it is worth, is to get an attorney that specializes in disability cases. Let them handle this, especially since this is likely to go to Long-Term Disability. Girl, you may be a bulldog who doesn't let go, but this isnot what you do for a living. In your well meaning efforts to bulldoze through the insurance company, you risk pissing off the wrong person off and having them enter a code into a field in the computer in such a way that the claims will be denied over and over. Let the lawyer send letters on your sister's behalf. Often, a letter on an attorney's letterhead (written by a paralegal) is all it takes to get the insurance company to roll over.

Insurance companies are for-profit entities that are trying to maximize their dividends for their shareholders, many of which are retirement plans that invest in the insurance companies. If you have such a plan, then you expect the plan to invest in companies that are doing exactly what the insurance company is doing. However, it is a fine line between serving their insured and meeting the expectations of their investors.

What you can do is to be a liason for your sister, between her and the attorney. Unleash the lawyer on the insurance company. Keep yourself reigned in.

Just my opinion. Worth what you paid. Hope this goes well. :)

Snakes (Rich )

PEC

I hope the insurance company isn't Cigna, if it is she is screwed.

Philip

drwtsn32

Insurance companies are the lowest form of scum, IMO.

I agree. Sorry to hear about this, Mary. :(

jeanniebeanz

Mary,

Snakes is right. There are two people who can assist your sister, a lawyer working with her doctor are your best bet. The amount of assistance your sisters company is going to be able to offer is going to depend on if this company is fully or self-insured for STD/LTD. Your sister can call her benefits department and find out by obtaining a Summary Plan Description (SPD). In the US, companies are required by law to provide this document if requested. If the plan is self-funded, the company Benefits Manager can work with the insurance company as well and find out what is going on that they would approve the Short Term for payment and now begin to kick and scream once LTD is approaching.

One possibility is that the STD is self-insured, thus it is the companies decision whether or not to pay, and the LTD is fully-insured thus it is the decision of the claims manager at the insurance company and the insurance company does not agree with the decision of your sisters benefits department to pay.

I play the goof-ball here, but in the real world, I manage benefits plans both self and fully-insured, some exceeding 35 million dollars, for international companies. This fight has to be very well organized and you will have a limited number of appeals through the insurance company before you will be forced to sue for this benefit. In my experience, suits take many years and in the meantime, the person may be forced back to work to support themselves in spite of great exacerbation of their condition. This then gives the insurance company fuel to fight the lawsuit since the claimant is working. A well organized appeal with the insurance company (if this is a fully insured LTD plan) with the direction of a disability lawyer working with your sister's doctor. I cannot overemphasize the need to work with the doctor on this and make him/her understand that this is not about getting a form filled out quickly, it is about carefully documenting the disorder/disability and listing strong medical opinions backed up with history and diagnosis within the file including office notes if necessary.

If I can help in any way, send me a pm.

Best regards,

Jean

Mary

My advice, for what it is worth, is to get an attorney that specializes in disability cases. Let them handle this, especially since this is likely to go to Long-Term Disability. Girl, you may be a bulldog who doesn't let go, but this isnot what you do for a living. In your well meaning efforts to bulldoze through the insurance company, you risk pissing off the wrong person off and having them enter a code into a field in the computer in such a way that the claims will be denied over and over. Let the lawyer send letters on your sister's behalf. Often, a letter on an attorney's letterhead (written by a paralegal) is all it takes to get the insurance company to roll over.

Snakes, you're absolutely right and I've already taken steps towards that. I emailed my old boss last night as he was a lawyer who helped people who had been in car accidents or bitten by a dog, etc., get the $$$ they were entitled to. I asked him to steer me in the right direction so I'll wait and see what he says. I was also talking to another friend last night who's the Secretariat for their union (government employee). She asked if my sister is seeing a Psychiatrist or Psychologist. I said "her doctor just gave her a note to go see one." She said that that will carry alot more weight with the insurance company than just her GP and that she knows several employees who were originally denied the claim, but won it on appeal.

snowbird

I have fought an insurance company and come off victorious!

Get prepared to dig in for the long haul.

My best to all involved.

Sylvia

EVER FIGHT AN INSURANCE COMPANY??

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