Articles Tagged with claim denied

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Medical records are an extremely important source of evidence in your disability claim. The records provide proof of the symptoms that disable you; they provide evidence of your treating provider’s opinion about your condition; and they provide proof of the period of time for which you have been disabled.

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Why Do I Have to File a Lawsuit?

When an ERISA long-term disability appeal gets denied, the next step is, potentially, to file a lawsuit in federal district court. Some clients already know that they would like to settle their case and ask, why can’t we just negotiate a lump sum settlement with the insurance carrier? Why do I have to file a lawsuit? In short, while plaintiffs’ attorneys would likely be amenable to negotiating informally, insurers generally refuse to come to the table until a formal complaint has been filed. The weight of a formal lawsuit perhaps creates more real incentive and pressure for the insurer to settle, and the process is well established and well understood. Having already filed suit, one benefit of going through the court process for a plaintiff is that, in the event a settlement can’t be reached, there is the possibility of taking the case to trial within a shorter timeline –the complaint has already been filed, a judge has been assigned, and certain deadlines have already been put on the court calendar. The desirability of accepting a lump sum settlement varies from case to case.

What Does a Win at Trial Look Like?

The internet provides patients with the resources to locate healthcare providers anywhere in the world. But whether your health insurance pay benefits for treatment with a health care provider anywhere in the world is another issue. Patients are often unhappily surprised when they discover that their health insurance policy limits them to healthcare only within their state or within the health insurance company’s network of providers.

The first step to understanding your health insurance coverage is requesting a copy of the policy. The policy dictates your healthcare coverage. Review your policy to learn whether your policy provides benefits if you go out of state, or out of the country, or see an out-of-network provider for treatment.

If the policy limits you to in-network or in-state benefits and you find a healthcare provider that is perfect for your needs, don’t lose hope. If you can show that there is no in-network or in-state health provider appropriate to treat you, you have a good argument for asking for out-of-network or out-of-state coverage even if the policy only approves in-network or in-state providers. The best argument will demonstrate that there are no in-network providers willing to take new patients or it is outside of their area of expertise. This argument will require through research through many telephone calls to in-network providers to determine whether they will accept the patient. Similarly with out-of-state providers, the argument requires research to demonstrate that there are no in-state providers available.

I want to preface this blog post by saying that I do not have a long-term disability. However, for 16 years of my life, I suffered a life-threatening illness –an illness that I was told that I would either a) die from or b) never fully recover from. Time and time again during those 16 years, I was told to give up hope for any semblance of a normal life, or just resign to dying prematurely. For 16 years, I believed that I should not have hope and there came a point in my journey when I finally gave up all hope and I resigned myself to dying. As fate would have it, on the very same day that I had resigned myself to dying, I ended up having life-changing encounters with human beings who inspired me to fight back and begin the journey to reclaim my hope. Reclaiming my hope was not easy, to say the least. It took me two long and arduous years to reclaim my health and to restore hope, overcoming the odds that were stacked against me. One of those odds was my insurance company –it had told me time and again that I was not sick enough to have my medically necessary treatment covered by insurance. Those two years of fighting for myself, fighting back against the mental defeat I felt because of insurance telling me that I didn’t deserve benefits, during those two years, there were times when it was incredibly hard to hang on to any semblance of hope. I had to remind myself that, “Hope exists. If for no other reason than the Dictionary says it’s a word.”

After I fully healed from the illness, I took my newfound hope and went on to serve as Policy Director on Capitol Hill for a small non-profit dedicated the illness that I had once suffered. In that role, I advocated to raise awareness of that disease, and to get a Federal Bill passed on behalf of people suffering that disease. Once again, the odds were not stacked in my favor. I ended up spending over 10 years advocating with that tiny non-profit on Capitol Hill. During that time, I lost more people to the disease than I can count (meaning, they died), and I heard from people all across the country who had lost loved ones to that disease. Trust me when I say, despite my faith in God, it was not always easy to remain hopeful –I admit that, at times, my hopeful spirit dimmed. But finally, in December 2016, provisions from the bill passed. That day in December was one of jubilation…and yet of humble quiet. The passage of the bill was subdued because it was long-overdue and long-awaited for 16 years, especially by the family after whose daughter the bill was named. The bill was named after Anna Westin who died in 2000 after insurance denied benefits for her treatment.

On ‘the Hill,’ I learned many things. One of the most eye-opening things I learned was: No matter how worthy the cause, the odds are stacked against you if you want to get a bill passed. In fact, in 2016, out of the 12,000+ pieces of legislation that were introduced, only 3% (three percent) passed/were enacted into law.

Aaron Monheim, age 34, lives in Spokane, Washington with his wife and three year old daughter. In 2019, Aaron was diagnosed with aggressive relapsing remitting multiple sclerosis which has been unresponsive to medications and leaves Aaron partially disabled due to frequent flares and relapses.

Aaron’s physicians recommended him to receive a treatment called hematopoietic stem cell transplantation, found to be particularly suited for his form of relapsing remitting multiple sclerosis. The treatment will effectively reset his immune system so it will no longer attack his central nervous system. The treatment is also less costly than the traditional medications for multiple sclerosis which have been unsuccessful for Aaron.

Despite having been referred to the treatment by his own Kaiser doctor, Aaron’s health plan, Kaiser Permanente, has denied benefits for the treatment claiming the treatment is not necessary or suited for Aaron’s condition.

Multiple sclerosis (MS) is a potentially disabling disease of the brain and spinal cord (central nervous system). In MS, the immune system attacks the protective sheath (myelin) that covers nerve fibers and causes communication problems between your brain and the rest of your body. Eventually, the disease can cause permanent damage or deterioration of the nerves.

Signs and symptoms of MS vary widely and depend on the amount of nerve damage and which nerves are affected. Some people with severe MS may lose the ability to walk independently or at all, while others may experience long periods of remission without any new symptoms. While there is no cure for MS, treatments can help speed recovery from attacks, modify the course of the disease, and manage symptoms.

The National MS Society estimates that more than 2.3 million people have a diagnosis of MS worldwide and approximately 1 million people over the age of 18 in the United States have a diagnosis of MS.

The Lupus Foundation of America estimates that 1.5 million Americans, and at least five million people worldwide, have a form of lupus. According to the Lupus Foundation of America most lupus sufferers are misdiagnosed or can go undiagnosed for years. The goal of Lupus Awareness Month is to inform practitioners, patients, care givers, and the public about how best to diagnose, care for, and live with lupus.

What is Lupus?

Lupus is a chronic disease that can cause inflammation and pain in any part of your body. Lupus is a type of autoimmune disease, which means the body’s immune attacks healthy tissue instead.

The term “long haulers” has started being used to describe people who have not fully recovered from COVID-19 weeks or even months after first experiencing symptoms. Some long haulers experience continuous symptoms for weeks or months, while others feel better for weeks, then relapse with old or new symptoms. The most common lingering symptoms are fatigue, body aches, shortness of breath, difficulty concentrating, inability to exercise, headache, and difficulty sleeping.

A new Northwestern Medicine study published this week in the Annals of Clinical and Translational Neurology analyzed 100 non-hospitalized COVID-19 long haulers and discovered 85% of patients experienced four or more neurologic symptoms which impacted their quality of life, and in some patients, their cognitive abilities. The study included 100 non-hospitalized COVID-19 long haulers from 21 different states who were seen in-person or via telehealth from May to November 2020.

The long haulers suffered persistent neurological issues, including brain fog, headaches, numbness/ tingling, disorders of taste and smell, and various myalgias. Additionally, 85% reported experiencing chronic fatigue. Among the long haulers who were in the study 47% also reported struggling with anxiety, stress, depression, and sadness. As a result, many patients experienced decreased quality of life and about half the patients in the study missed more than 10 days of work.

One of the most crucial pieces of evidence in supporting a long term disability claim is the opinion of the claimant’s treating physician that he or she is disabled.

Many physicians are more than happy to assist their patients with forms required by the LTD provider and in some cases, narrative accounts of their patient’s disabling condition.

Sometimes, though, even with the support of your physician, problems can still arise. Often, this is because of the office visit notes your physician makes with each of your visits. Phrases such as, “doing well,” “symptoms improved,” “responding well to medication,” while meant as shorthand by the doctor that her treatment plan is working, are often used by the insurance company to conclude that you are no longer disabled.

Health insurance plans provide coverage only for health-related serves that they define or determine to be “medically necessary.” Medical necessity refers to a decision by your health plan that your treatment, test, or procedure is necessary for your health or to treat a diagnosed medical problem.

Most health plans will not pay for healthcare services that they deem to be not medically necessary. The most common example is a cosmetic procedure, such as the injection of medications to decrease facial wrinkles or tummy-tuck surgery. Many health insurance companies also will not cover procedures that they determine to be experimental or not proven to work.

Hereditary Leiomyomatosis and Renal Cell Cancer (“HLRCC”) is a very rare genetic condition that was named in 2002. It is also known as Reed’s Syndrome. HLRCC is a disorder in which affected individuals tend to develop benign tumors containing smooth muscle tissue (leiomyomas) in the skin and, in females, the uterus. This condition also increases the risk of kidney cancer. Surveillance and monitoring for HLRCC is recommended starting at around age 5-8 years.

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