Chronic Fatique Syndrom - MED: Getting booted from LTD by CIGNA

Author

MED: Getting booted from LTD by CIGNA

BONEDFISH@AOL.COM

2006-07-17, 9:20 pm

I haven't posted for a long time - thought you might be interested in this
and I'll try to be brief, though if you have any questions I'd be happy to
answer them if I can. I will also post the outcome of all this.

I'd also love to hear anyone else's experience with this and your "tips".

Here it is: I've been on long time disability since 1997. In 1999, I also
began recieving Social Security Disability. The last couple of years, CIGNA
has requested more paperwork than usual. In May, I was told I had to take a
Functional Capacity Exam. I was not allowed to schedule this on my own - they
set it up.

The test is done on two consecutive days, about 3 hours each day. They test
how much you can carry, lift, push. They have you crawl, do stairs, do an
overhead task, and some manual dexterity tasks.

As it turned out, I was feeling pretty good the days of the tests. Spring
and Fall are the best times of the year for me, as they knew from previous
questionnaires.

They also had me under surveillance for 4 days - during the 2 days I had the
tests, and the 2 days immediately before and after.

They say I can work full time at light or restricted duty - not at the job I
previously held, but another type of job in keeping with my previous pay scale
and education. I believe they are wrong.

They paid me one more "hardship" check which basically covers the month of
July, but there will be no further money until I win an appeal. I have an
appointment tomorrow with a disability attorney to find out what I can do about
this.

My best wishes to all of you who may be going through a similar problem.

I know there were some postings some time ago from others regarding these
same types of disability issues.....Can someone please tell me how I can see old
posts?

Laura

ahimsa

2006-07-18, 4:22 pm

Hi Laura,

As someone who has been through the process of fighting for LTD
(Long Term Disability) benefits, I feel for you. It seems like all
insurance companies (and employers who provide "self-insured" LTD
plans for their employees) play the same tricks. They want to
reduce the number of claims they have to pay out. It has nothing
to do with whether a claim is valid or not! It has everything to
do with keeping their profits as high as possible.

My first suggestion is get a lawyer - but you already did that. :-)

My second suggestion is to join the DISINISSUES mailing list at

http://groups.yahoo.com/group/Disinissues/

This group is helpful for answering specific questions that you
may have as you go through this fight.

My third suggestion is to make sure you have at least one doctor
(preferably two or three) who agree that you are too sick to work
AND who will write letters (perhaps for a fee to cover their time)
to help support your disability claim. If the doctor(s) will work
with your lawyer to write the letter in the correct format then
that's even better.

My last suggestion is try (it is hard!) to be as detached from
the process as possible. It is not about you! It is not about
what is right vs. wrong! It is about what they can get away
with legally and not have to pay you. I was so disillusioned
about this but it helped me to keep from getting too depressed
during my fight. It is so hard to keep thinking, "But really,
I'm sick! I'm not lying! Here's all my medical evidence! Why
won't they pay me?" It is better to let it go and just focus
on working with your lawyer to win your claim.

If your claim is covered by ERISA laws (e.g., LTD benefits
are provided as part of employee benefits package) then your
work will be harder than if it is a private policy. The bar
for winning/losing an ERISA claim is so much higher than for
most disability claims. ERISA laws are written in favor of
the insurance company, not the patient.

Here are some links with ERISA information:

http://erisa.petti-legal.com/

http://members.aol.com/MMckuin/erisa.html

It's a real mess.

Last of all, here's one way to search through old messages
posted to CFS-L (gatewayed to alt.med.cfs). Use this link:

http://groups.google.com/advanced_search?hl=en

Put "alt.med.cfs" in the field for Group and use the keywords
you want (such as disability or LTD) to find old messages.

Hope this helps!

Hugs,

Marjorie

Commit random acts of literacy--Join bookcrossing!
http://www.bookcrossing.com/mybookshelf/ahimsa

Cathy Broxterman

2006-07-18, 9:21 pm

Thanks Marjorie and everybody else who posted about this. The insurance
company made their determination based on the records of one doctor who
I had quit seeing because she wasn't helping me and ignored the records
of 3 other doctors who said I was disabled. The doctor that I quit
seeing dismissed my complaints when I had meningitis and saw her because
I was having trouble walking and was falling all the time. She put down
as the reason for visit, "bruises". The following day I ended up in the
hospital on IV antibiotics. The hospital staff was pretty condemning
about the fact that she hadn't even sent me for a spinal tap. I guess
that scenario gives me pretty good legal ammunition for saying that she
wasn't treating me adequately and that her saying I wasn't disabled is
questionable. I'm afraid that the statute of limitations has probably
passed for me to file a suit, though. Does anybody know anything about
that?

I have been taking it personally that I was denied benefits. It's like
everybody else who has been telling me I'm not really sick and I just
need to get a job. I did see an attorney after I was denied, and he
wouldn't take my case and that stopped me in my tracks. Right now I'm
so miserable from my 3 hour per day job and the yard work I'm doing in
over 100 degree heat (it hit 105 today!) that I'm in tears. If I could
get that long term disability benefit I could quit this job and have
money to pay someone to do the yard work.

Cathy

BONEDFISH@AOL.COM

2006-07-19, 4:21 pm

Hello Margorie,

Thanks for your supportive response and useful information to my email
regarding my fight with long term disability.

You included this info:

> If your claim is covered by ERISA laws (e.g., LTD benefits
> are provided as part of employee benefits package) then your
> work will be harder than if it is a private policy. The bar
> for winning/losing an ERISA claim is so much higher than for
> most disability claims. ERISA laws are written in favor of
> the insurance company, not the patient.

Yes, my benefits were through my employer - in fact, I had paid an additional
sum while working to have extra benefits in the event of disability (standard
employee benefit would have provided 50% of my pay, the additional payment on
my part gave me 66% for long term disability). And what you wrote pretty much
sums up what the disability lawyer said yesterday.

If I am remembering what the attorney said correctly, this is what will
happen and how it shakes out:

The long term disability company gives me 180 days to appeal from the time
they notified me of termination. They have already eaten up over 30 days of
that time by requesting another letter from my doctor which did not change their
minds. (They are insisting upon "real, observable and measurable data").

The longer we wait in that time frame to file our appeal is to our benefit.
That gives us more time to get "data" that will support my claim. If we would
file now, we would not have additional information, and CIGNA would use the
next 45 days of the 180 day period, before they issue their decision which will
be "NO." Collecting data at this stage to show I cannot work is very
difficult. They already have all the "proof" they need to deny my claim. I now have
to "prove" otherwise. I will of course, have to pay for any testing/doctor
visits that will support my claim.

Then the appeal will go to the federal level. A judge will look at the
information that is collected during this appeal period. They will not talk to me,
nor will I be given an opportunity to make my case.

He says I've got about a 50/50 chance of "winning." And that is a relative
term. First they will calculate what my case is "worth." They base it on how
much you were receiving per year from LTD multiplied by the number of years
until you retire. Then they determine the present value of those dollars. My
case is worth $163,000 (how much I would collect if I were to continue on LTD
until retirement) and the present value is approximately $60,000 - (how much it
is worth today). I think this is an ignorant way of doing it - this isn't
the frigging lottery. I have to live on this money...I can't invest it and
watch it grow to $163,000.

The judge will decide whether you get all of that present value dollar amount
or nothing - that is, they will decide in favor of CIGNA or in favor of me.
Sometimes the long term disability company and the lawyer will settle on an
amount instead and that amount could vary in my case between $30,000 and
$50,000. This process could take over a year before it is finalized.

It is unusual, according to the lawyer, to actually have the LTD company
reverse their decision during the appeals process and if they do, they must back
pay you for your appeal time and reinstate your benefits. (Then at a future
time, they usually deny you again and start the whole process over.) It is, he
says, better to just get the settlement, however, I'm not sure I agree.

The lawyer's fee for fighting this claim is usually $3,000 up front. That
fee covers the appeal to CIGNA and the appeal at the federal level. He also
gets 30% of the settlement. The settlement is also taxed. In my case, he's
willing to take $500 up front and 35% at settlement, which could leave me with
around $13,600 assuming they settle for $30,000.

In the meantime, I am not allowed to even try a part-time job through social
security (which I really don't think I can do - have tried various things many
times before) or I will jeopardize my appeal. So, I am left with a deficit
every month - until I possibly win - of $70 a month just to make my house
payment, utilities, bankruptcy and car insurance. I may be able to renegotiate my
bankruptcy amount according to my other attorney and I have applied for food
stamps.

I am not really surprised by all of this -- after all, these companies are
not in business to actually help people or to pay claims. They are in business
to make money and to make investors happy. "Hurting the hurt to make the
wealthy wealthier" is NOT a mission statement I would be proud of.

But I am devastated today, may feel less so tomorrow, and regret like crazy
not paying more attention in the past to posts on these issues. I can see now
that I was "too optimistic" on all that paperwork asking me "how I felt, what
do you do in day, etc.," and in so doing, may have sealed my own fate.

The best advice the attorney said yesterday was this: "Money is important
but it isn't what makes you happy. We need three things in life. We need
something to do, someone to love, and something to hope for. You have something to
do - you are going to fight the claim denial. You have a dog and 2 cats that
are depending on you. And you can hope you will win your appeal."

It is difficult right now to see all of this as an opportunity, to embrace
the risk and fear and let the Phoenix rise, but if I don't, I won't have the
strength to go on. And I sure as heck am not going down without a fight.

Thanks for the website addresses for ERISA links and info. - that's my next
stop.

Hugs and best wishes to you too.

Laura

BONEDFISH@AOL.COM

2006-07-22, 9:20 pm

I am in a big quandry and am having brain fog and difficulty finding info. on
this online. Finally figured out how to join disinissues too, but not having
lots of luck yet with this specific problem.

I recieved in the mail on Friday a contract from the disability attorney. I
need to sign this and send $$ in order to begin work on my appeal with my Long
term disability insurance company - the clock is ticking.

However, the more read about what these disability companies are doing, that
these large ERISA covered LTD insurers are actually writing in two year
limits, etc. and giving employers discounted rates if they allow them to do so, the
more I believe that they can't get away with this forever.

If I pursue my claim, it is unlikely according to the attorney, that they
will reinstate my benefits. I will have to sue in federal court. If I get a
global settlement at the federal level, it "ends all entitlements". That means I
would not have any claims later if my insurance company, along with all the
other ones who are denying valid claims, is found to be discriminatory, etc.
and forced to pay all of the valid disability claims for CFIDS that they are
currently denying.

I am actually considering not appealing/suing now so I can sue them later
when they all get stung for their practices. Course, in the meantime, there is
the problem with groceries....

Am I nuts? Is there anyone else there out there considering the same thing?
And maybe I am putting the cart in front of the horse...perhaps I will get
lucky and get my benefits reinstated instead.

I'd love to hear your thoughts on this.

Laura