posted
hi i have been receiving LTD checks from Cigna for two years and now they have denied me. they have a clause, like so many insurance companies do, that says: after 2 years of benefits if my "...disability is caused by or effected by" any mental health disease like depression, benefits are stopped. i am overwhelmed by the reading i have done on this site and a million others on disability documentation the past few days. So it would be a huge help if someone out there could give me 1 or 2 specific sentence examples that mean my lyme, pain, and fatigue disability is not effected by my depression.
i thought about saying that if i only had depression, i could work and if i only had lyme i could not work. i have had to have my antidepreeant drugs changed a few times after a few years on one drug. i have been on them for years beginning a year into my diagnosis and i have never missed many days of work except for other things like flu, colds, etc.
cantgiveupyet
Frequent Contributor (1K+ posts)
Member # 8165
posted
is this an ERISA policy? I feel for you im battling the beasts now. Pure evil.
From what I have read, if anywhere in your file it has a diagnosis of mental health illness then after two years they cut you loose. Its their way out.
Ive heard that the new policies now have fibro and cfs clauses.
My suggestion would be to call ERISA lawyers if your policy is ERISA and get their opinions.
You can PM me and I will give you some names.
Are you getting SSDI?
-------------------- "Say it straight simple and with a smile."
"Thus the task is, not so much to see what no one has seen yet, But to think what nobody has thought yet, About what everybody sees."
-Schopenhauer
pos babs, bart, igenex WB igm/igg Posts: 3156 | From Lyme limbo | Registered: Oct 2005
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daise
Unregistered
posted
Oh np,
That's awful. That makes me angry!
Idea: Do you have a lawyer to help you?
Perhaps a free senior center lawyer to help: they might help or atleast send disabled people who aren't seniors in the right directon, for community help.
I'm not sure what LTD checks are. I hadn't realized some Cigna plans paid for Lyme meds. (Apparently, they are?)
Just an idea: Can you stop the depression medication with the insurance company, keep taking your Lyme meds and pay for your depression med yourself--under the insurance companies radar?
If you can't afford it, perhaps your university or your state has a program for meds--and you can get your antidepressnt under the radar of your insurance company!
You may need to see a doctor not at all connected with your insurance company, who can write the prescription.
Maybe Prescription Hope will help (although they probably will need to check with your insurance company as to why they won't cover it:
Idea in the other direction: Have you tried keyword searches on the Internet to find what others have done? That is, what legal information you need to know about? For example, "Cigna mental health." Or, "insurance mental health."
You could ask your doctor what routes others have taken. This must be a big, nasty issue. I never heard of it. I'm appalled.
What does your state do about the people who are in your shoes? Think of the people who are schizophrenic or bi-polar and so on. What happens to them? What about those with depression?
I guess that would be the first thing I'd check on: try calling your state insurance commission and ask: what do I do now? Will you direct me, please, to a state program for my depression medication?
If the first person doesn't help you, ask to please speak with their supervisor.
If that doesn't work, try calling your congressperson's office and speak to their HEALTH AIDE. Ask the same things. They ought to know.
Or maybe call your neighborhood's state legislator.
Then maybe you can continue with Lyme meds through Cigna.
daise
[Edited to add:] Or try calling your state health department and ask to speak with their mental health person.
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bettyg
Unregistered
posted
so sorry to read this!
2 suggestions for you; I know nothing about LONG TERM DISABILITY, LTD: ***********************
1. go to SUPPORT and look for a post about INSURANCE HELL, and then copy your link here and sent it by private message to:
*** connie mc, non-lawyer representing folks in SSDI action
*** to bugg, he has some expertise, and might be able to give you some good advise on where to start ok!
2. do you have my newbie package, at the end is all about getting SSDI, disability insurance benefits, etc.
look for the DISINISSUES WEBSITE, disability insurance issues,
join there! or are you a member?
copy your post there to group! moderator SARAH SHAPIRO edits all posts, and will post what she choses too....
it's nothing like here ... strictly info only and FILES THERE so check them out too!
posted
If you are getting your antidepressants through a psychiatrist, then talk to him her about getting samples for you (all docs get free samples from the pharmaceutical reps, so docs can try out the meds without patients).
Also, many of the pharmaceutical companies have special programs to provide medications for persons who have no other means to pay for medication.
I don't know if this will help your insurance problem though, because if you do see a psychiatrist, then he is billing your insurance for your office visits.
If a regular doc is prescribing the antidepressants, he or she could still investigate the special programs, but probably won't have much in the way of samples.
I would also recommend talking to your doc about putting in writing to the insurance company that your tx for depression is unrelated to, and does not exacerbate the symptoms of lyme, for which you are being treated.
In response to daise's questions about mental health tx:
Most insurance companys (I'd say all, but I can't swear to it) provide limited mental health coverage, for both inpatient treatment and medication.
In Jersey (where I live) most of the people that I worked with with severe mental illness ended up not only destitute, but in serious debt, from the treatment for their mental illnesses. Which they didn't ask for, often were hospitalized against their will (committed) then stuck with hosptial bills that would drive many into bankruptcy.
I do believe that the laws have changed, but they used to have lein laws that allowed the hospitals go after the patients family members for payment of these bills (thus driving the patient's support system into poverty as well).
I could go on indefinately about the plight of the mentally ill, but this isn't the place.
Beleive me, if insurance companies could get out of covering mental health tx, they would (psychotropics are way more expensive than abx) but they just haven't figured out a way to get away with saying that there is a "Post Psychotic Syndrome" for which treatment with medication is not beneficial, so no medication is covered.
Daise, our cigna also has covered lyme tx, with the only problem so far being zithromax, they only cover 6 days a month, the rest is out of pocket. Sometimes we have had to make extra copays, but all in all, we haven't had big trouble yet.
posted
If your long term disability was originally approved based on mental health diagnosis then I don't think there is anything you can do unless you had not been diagnosed with Lyme at that time.
If the depression or whatever diagnosis came first and you only found out after your benefits started that you had Lyme and tickborne illnesses then you MAY have a case, but doubtful that benefits would continue without a long drawn out legal battle. But if you eventually won, then the company would be liable for any missed benefits. Hard to say who would have to pay the lawyer.
This is one of the reasons hubby fought so hard to have his diagnosis say Lyme disease since he had 3 psych admits early on before we knew what was wrong with him.
Surprised that you actually won LTD benefits and that company did not offer lump sum settlement -- of course if benefits were paid based on psych diagnosis then they knew benefits would stop after 2 years and that is why they paid up.
We all know the depression is/was caused by Lyme etc, but if you knew about the Lyme at the time benefits were awarded and accepted the payments based on psych diagnosis then I don't think you can "change your diagnosis" at this point.
When did you start antibiotic treatment -- before or after the benefits started? Very important point.
Rules for social security and long term disability are totally different.
Bea Seibert
Posts: 7306 | From Martinsville,VA,USA | Registered: Oct 2004
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The 2 year rule for psych diagnoses is very common with long term disability companies and perfectly legal.
The rationale is that with appropriate psych meds and counseling etc a person should be able to resume a normal work schedule because the meds have the so-called "disease" under control.
Bea Seibert
Posts: 7306 | From Martinsville,VA,USA | Registered: Oct 2004
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cantgiveupyet
Frequent Contributor (1K+ posts)
Member # 8165
posted
LTD is basically just a loan really, short and simple. They put clauses in like the mental illness clause, also the repayment once you win SSDI.
They are evil people, pure and simple. They cherrypicked one small comment about me having anxiety for a gyn exam(which later was proved to be guarding by my physical therapist)
I made sure now to not fill my xanax, which i was using as a muscle relaxer.
Everyone mentioned very key points above, especially Bea about the timing.
Again feel free to PM me and I can help when I can.
-------------------- "Say it straight simple and with a smile."
"Thus the task is, not so much to see what no one has seen yet, But to think what nobody has thought yet, About what everybody sees."
-Schopenhauer
pos babs, bart, igenex WB igm/igg Posts: 3156 | From Lyme limbo | Registered: Oct 2005
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Bugg
Frequent Contributor (1K+ posts)
Member # 8095
posted
NP--
Before you sign/write/call them about ANYTHING, I HIGHLY, HIGHLY SUGGEST CONTACTING AN ATTORNEY. I can't tell from your e-mail whether your policy is an employee-funded plan governed by ERISA or whether it's a plan governed by your State's insurance laws. Regardless, I have a great attorney with whom you should speak....He's not going to charge you for the phonecall and he takes all of his cases on contingency (meaning, he only gets paid if you get paid)...
PM me if you want his contact info and I'll call him today and let him know you will be in contact...
Posts: 1155 | From Southeast | Registered: Oct 2005
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Bugg
Frequent Contributor (1K+ posts)
Member # 8095
posted
NP--
On a personal note to you. DON'T beat yourself up regarding anything in your medical records and/or your LTD applicatin related to mental health. As was stated by in an earlier post, the two-year cut-off clause is almost standard now in all LTD policies.
Many insurance companies will try to manipulate and use anything they can in your records or your application to show that your illness actually engendered from a mental health issue. We all know it's crap but they do it to everyone.
Just want to tell you to not take anything the insurance company does personally. Just remember, though, if your policy is governed by ERISA and you appeal the decision without a lawyer, you will most likely "close the record"---meaning you cannot have any form of discovery against your insurance carrier and you're stuck with what you've put in your appeal.
Posts: 1155 | From Southeast | Registered: Oct 2005
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posted
thanks for all the replies. i want to give you a bit more info to challenge some more thoughts from you all tht might help my docs.
cigna doesnt tell me what my award is based on, whether it was for mental or lyme or whatever.
i have been on antibiotics for 12 years, antidepressents for 11. as i said i have not missed much work in the past, only for acute illnesses.
i also have the diagnosis of chronic pain, receive long acting narcotics, and see a pain specialist.
again, how do we state that depression does not immpact my disability caused by chronic Lyme with neurocognitive symptoms, chronic pain from myalgias primarily, and chronic fatigue (but not fitting criteria for chronic fatigue syndrome)?
i was a nurse practitioner pre disability so had a high level of function, and now cant work anymore because of my pain and neurocognitive and fatigue symptms.
does this info help?
also i dont know what you mean when you say to "pm you" stated in your replies. i am new at this sorry.....
Posts: 68 | From washington/oregon | Registered: Apr 2001
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Bugg
Frequent Contributor (1K+ posts)
Member # 8095
posted
NP--
Did Cigna send you a letter informing you of the reason why they are ceasing benefits? If so, did they cite a particular mental health issue?? If so, that's where you need to direct your attention/focus.
What many people don't understand about LTD and insurance carriers is that REGARDLESS OF THE GROUNDS UPON WHICH THEY GRANT BENEFITS, MANY LTD CARRIERS WILL TRY TO USE THE MENTAL HEALTH PROVISIONS TO LIMIT THOSE BENEFITS TO TWO YEARS...
If they granted the benefits on the basis of mental health, they can still try to use the clause to limit your benefits; if they granted the benefits on the basis of lyme or CFS, they can still use the mental health clause against you by citing mental health treatment in your medical records or on your LTD application....
..You want to try to show that Cigna's decision doesn't 1) meet the definition of the mental health limitation in the policy or 2)is contradictory to a prior confirmation of no mental health issues or 3) is based on a lack of evidence (or all 3 of the aformentioned)...
A good attorney can help you review any previous correspondence from Cigna,their grounds for denial, and your policy and try to show why Cigna's denail of benefits is "arbitrary and capricious"...
I'm concerned that your policy is goverened by ERISA and you really need an ERISA attorney to help you appeal your denial or you can inadvertently waive your rights.
A "PM" means a private message. Do you see the two people holding hands by the envelope to the right of my screenname? You just hit that and it will e-mail me privately....that way I can put you in contact with an attorney...
Please note the aforementioned is not legal advice...just help from another lyme patient...
Posts: 1155 | From Southeast | Registered: Oct 2005
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I had two years of LTD with an insurance company through my work, based on medical illness. After two years, they denied further payments based on medical, but gave me two more years mental health, during which they were reimbursed when i finally won SSD.
When I was denied the medical, I got a lawyer (even though they had started paying me based on mental). He was one of two lawyers in the state who deal with ERISA, fighting the insurance companies.
For six months, we gathered information. I had statements from several doctors stating that I was disabled (the lawyer, who has won many times against this insurance company , created the letters and had the doctors sign). In addition, I had a pain management doc who knew a lot about everything and was my main physician for the first two years of my illness. He wrote a 30-page report about me and my illness using his records and those of my other doctors, like my neurologist, LLMD and psychologist (did not state I had Lyme, just said it was one of the things that was being looked at). It was incredible. However, his degree was in psychiatry.
I paid a lot for the lawyer, and a decent amount for the report. I had a lot of good medical records. I had a neuropsych eval. Etc. But I lost the appeal.
My lawyer contacted the insurance company lawyers and stated all of the problems with their denial, and because he had just won a case against them, identical to mine, he thought they might settle. They refused. They insisted it was mental. And mental health disability ends after two years. My lawyer said that he would no longer represent me because he really felt that I would lose, without a stronger showing from "medical" doctors.
When we were gathering info last fall, I had a neurologist write a short letter, and sign the lawyer's letter, all saying I was disabled, but it wasn't strong enough because he isn't sure what I have (doesn't believe in Lyme). My LLMD would not do disability forms, nor would any of my doctors except my psychiatrist and psychologist. Which is why I lost. They are mental health, even though my psychiatrist practices medicine.
This is a big hardship. We will have to move. My guilt is huge. I was 40 and healthy when I met my husband. He had custody of two young daughters, I had no children. We got married, spent a lot of money adding on to his house. Only 1.5 years after our wedding (2.5 years after we met), I got sick. I've been sick 5.5 years. I was brought down by this illness when I was at the top of my game at work. Now I lost this, and all I have left is SSD. At least I have that, but I am a burden to my family. I have never been more depressed.
My question - how do you win against the private insurance companies? Do you all have doctors who will fill out your disability forms? My new LLMD won't do it, my old one won't, either. None of my doctors will, except the psychiatrist and psychologist and the psychiatrist just retired. The only way to win is to have a doctor friend or family member that has known you forever and supports you (and is younger)? What do the rest of us do? I will need to find someone because my psychologist will be retired by the time SSD rolls around again, and I need a medical doctor for the paperwork, anyway.
lucy
Posts: 43 | From Grand Rapids, MI | Registered: Aug 2007
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cantgiveupyet
Frequent Contributor (1K+ posts)
Member # 8165
posted
lucy i really feel for you. Have you joined the yahoo disinissues group that is listed under general on this site.
The mental health clause is a tough one. I was kicked off way before i even reached the two year mark, while in appeal i won ssd, so off went the money back to the LTD. Im still enraged about that one. Im in 2nd appeal
I went for an FCE and neurosych. My lawyer asked my dr's to fill out a form , which basically was them stating what I could and could not do and if they agreed with the fce. My PCp balked at it, said NO WAY...and just wrote a letter.
He said, he couldnt evaluate me in 5 min.
Not sure what the other dr will do...but im not too hopeful.
this is why im in appeals to begin with the dr's wouldnt fill out the forms. I drove 2 hrs to a llmd that would do the forms, but in the end he grew tired and 'lost' them.
the forms bascially are functional capacity forms, saying how much i can lift etc. But my job was sedentary and my illness is urological mostly in nature.
Was your lawyer one of the top ERISA lawyers?
Ive talked to almost everyone of them on the East coast.
feel free to PM me, i will help as much as I can. I know that yahoo site is a great one, and someone on there may be able to help you.
-------------------- "Say it straight simple and with a smile."
"Thus the task is, not so much to see what no one has seen yet, But to think what nobody has thought yet, About what everybody sees."
-Schopenhauer
pos babs, bart, igenex WB igm/igg Posts: 3156 | From Lyme limbo | Registered: Oct 2005
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posted
NP, I like the way one of my physicians phrased his comments on my depression. It was something like "moderate depression, most assuredly SECONDARY to the ORGANIC debilities of Lyme". Which proves it's a medical complaint and not a mental complaint. If you can get any of your physicians to sign off on that type of evaluation, it can only help your case.
I too am at my 2 year limit on my Long Term Disability, but it's from Aetna. They have continued to extend my payments month by month as they collect information from all my physicians. I keep my fingers crossed that they give me a permanent approval soon.
I have also filed for Social Security, even though my heart breaks over the thought that I'll be taking away from my parents' retirement when I have a perfectly good LTD payment from insurance my company paid for.
I'm surprised to hear so many people have trouble getting physicians to fill out their disability forms. I had 2 LLMD's perfectly willing to fill out forms. I just paid them a small fee for their time.
I wish you all the best of luck with your appeals.
Posts: 168 | From Delaware | Registered: Aug 2005
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bettyg
Unregistered
posted
hi!
be sure to read the post i copied over here about CALIF LOS ANGELES DA collecting info on denying payments, canceling insurance, etc.
why don't you both use this opportunity to write him about your situation??
read over the form i posted there carefully!! **********************************************
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