Here is a little background. If you just want to see my question go to the last paragraph.
I applied for a leave from a work through a short term disability plan they have.
I knew it would be tough with lyme and as I somewhat expected the insurance company denied my claim.
First it was not the diagnosis but that my doctor didnt include enough recent appointment and clinical notes.
After more was supplied they said now they needed more recent positive lyme tests. My positive wb and pcr were from 2008.
After explaining lyme is a clinical diagnosis and the 2 positive tests just reinforced the diagnosis they came back with it being denied because I had not physically seen my doctor in the last month. I am in colorado and he is in NY. I told them its not feasible or necessary for him to see me in person every month. I have a local doc that works with my llmd and sees me once a month in person. That wasn't good enough.
So they denied the claim and I have 7 days to provide objective medical records or tests to justify the leave.
I did a search on that term in google and the first result was a lawyers website talking about how insurance companies use this term and method when they are trying to get out of paying a claim. He said its usually impossible to provide that for things like lyme, fibro, cfs.
So I am going to ask the insurance company what test or record I can provide them with that will satisfy them. I have a feeling they won't be able to.
Can anyone think of an test, lab, etc that would show objectively why a person couldnt do their job with lyme?
Posted by lou (Member # 81) on :
This is pretty typical. They are weasels and I doubt any test would prove it to them. If you came up with a positive, they might even call it a false positive.
Don't know if this would work with such dishonest companies, but a better approach might be to document the disabilities that make you unable to work, not the diagnosis. As we know, proving lyme is difficult. Just a thought.
And those disabilities would not have to be documented by a lyme doc a long way off.
Posted by Bugg (Member # 8095) on :
N2themystic- Is this a self-funded plan through your employer (ie governed by ERISA laws)? Before you submit ANYTHING, I would consult a disability attorney and obtain advice about what to submit.....
You need to understand the definitions within the policy to determine what qualifies as "disabled" under the policy.....
You also need to understand "under the policy" what the insurance company is allowed to request or not request....ie they may be outside the purview of the policy by requesting recent lyme tests....OR, they may have already waived their rights to request these additional tests by NOT initially requesting them in making their initial determination......
I really encourage you to contact a disability attorney who deals with private insurance company disability (we're NOT talking about social security disability).....
Posted by n2themystic (Member # 27315) on :
Lou- my doctors did focus more on the symptoms and treatment and how they affect my ability to work than the diagnosis. They said symptom and treatment impact they gave were subjective and they need objective. How can a test show pain, fatigue, brain fog, etc? It cant and I am sure they know that.
Bugg- It is a plan my company offers but is contracted out through an insurance company called Matrix. I asked them to provide in writing why they denied the claim and based on the reasons my doctor says I can't work, what tests or records would the accept. I bet they won't be able to provide anything. I am looking into an attorney who specializes in this.
Thanks
Posted by lou (Member # 81) on :
Good luck. Bugg had a good suggestion to look at the policy and see what it actually says. Maybe you have already done this.
Excellent idea to find attorney. Someone I heard about got an attorney for a disability case, company pulling all sorts of tricks, when the attorney showed up to take a deposition at the company, they folded. But not everyone will get an attorney in such cases. And the companies know that.
Posted by Bugg (Member # 8095) on :
n2THEMYSTIC--
I don't want to get too technical but, generally, arrangements with private insurance companies are usually governed by either state insurance laws or ERISA laws. These are two entirely different sets of laws. If your plan is a SELF-FUNDED plan through your employer then it is most likely governed by ERISA laws. This is an EXTREMELY complex area of the law and you can inadvertently waive certain rights you may have by providing the insurance company with information YOU SHOULDN'T BE GIVING THEM.
Yes, I would specifically look for an ERISA attorney with experience. If the attorney tells you he doesn't have experience with ERISA cases, FIND ANOTHER ATTORNEY. You need one experienced in this area as these are VERY complex laws. I would ask an attorney friend for a referral to an ERISA attorney or call your State Bar Association.
The amount you may have to pay this attorney just to get some advice on how to respond to the insurance company's request should not be that much. It will be worth it if he's able to help you get payment under the policy.
If you want, I can PM you the name of the amazing ERISA attorney that I used. He's located in TN but that doesn't matter for ERISA since that is a federal set of laws. If he can't help you, he may be able to refer you to an ERISA attorney in your area...
Just PM me if you decide you want his info....
Posted by Rumigirl (Member # 15091) on :
By law the insurance company has to provide you with the denial in writing. Ask them to send it to you ASAP.
In addition, request in writing that they send you ALL the documents, policies, and information they used to make this decision. Again, by law they have to provide this. I forget what they call this request.
These documents will be important to use in your defense.
Yes, get a lawyer who specializes in this; it will pay off in the end. Don't let them win this one.
Get the CALDA Lyme Times Insurance Issue. It is extremely helpful. Even though this is disability, some of the same info will apply. It's an invaluable resource. Google CALDA.
Posted by Bugg (Member # 8095) on :
n2THEMYSTIC-
I meant to mention to you as well that the standard for review on appeal of a denial under ERISA is whether the insurance company acted in an "arbitrary and capricious manner" in denying your benefits. In other words, based on the evidence the insurance company was provided did they act in an arbitrary and capricious way by denying your benefits. It really actually has nothing to do, on its face, as to whether or not you're disabled. It actually has to do with the EVIDENCE submitted to the insurance company....hope this helps in some small way...
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