Articles Tagged with insurance coverage

In addition to dealing with short term disability benefits, long term disability benefits, and health insurance denials, many of our clients are also tasked with keeping track of changes to their Social Security benefits. Here are some of the changes that will take effect on January 1, 2020 for Social Security recipients –

  • Social Security recipients will get a 1.6 percent cost-of-living adjustment (COLA) in their monthly benefits starting in January. The average individual retired Social Security beneficiary is expected to see a monthly benefit jump from $1,479 to $1,503, an increase of roughly $24 per month or $288 for the year.
  • As a result of the COLA, the maximum monthly benefit a single recipient can get also will grow. That benefit will increase from $2,861 per month in 2019 to $3,011 per month in 2020.

In his October 28, 2109 Opinion piece published by The Philadelphia Inquirer, Ross Waetzman opened with this harrowing sentence, “I almost died because of insurance prior authorization rules.” His story went on to share the details of how he nearly died as a result of the decision made by his insurer, Independence Blue Cross (“IBC” or “IBX”), to deny authorization of benefits for a test that had been recommended by Mr. Waetzman’s cardiologist.

The test Mr. Waetzman’s cardiologist had recommended was a cardiac catheterization. The test was necessary because Mr. Waetzman’s history of chest pain had been increasing in intensity, despite lifestyle changes he had made in an attempt to curb his symptoms. The cardiac catheterization was recommended by Mr. Waetzman’s cardiologist after less-invasive tests had been performed. Those less invasive tests, an EKG and a coronary calcium test, revealed that Mr. Waetzman was in the top 10% for his age and race for calcium deposits on his coronary arteries. With such deposits known to result in reduced blood flow to the heart, the cardiac catheterization was recommended to determine if Mr. Waetzman’s chest pain was a result of a blocked artery.

Unfortunately, when Mr. Waetzman’s cardiologist, Dr. Kenneth Mendel, called IBX, he was informed that “prior-authorization” for the cardiac catheterization was denied. IBX claimed that Mr. Waetzman did not meet all the necessary criteria to have the test and his only available option was to appeal the denial.

Attend our October 2 Webinar About Insurance Coverage

You have had or are considering explant surgery.  We understand the physical and emotional pains that made you decide on the procedure.  We also understand that thinking about insurance coverage should be the farthest thing from your mind.

We have spoken with so many women about their troubles getting insurance coverage for these explants, that we thought it may help to put together some ideas, facts and resources that may resolve at least one part of these ordeals.

The Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001 et seq., was enacted to provide minimum standards for voluntarily established plans by employers in the private industry for the benefit of their employees. Despite its name, ERISA also applies to disability benefits an employee may be entitled to if s/he becomes unable to work due to a disability, whether or not it was work-related.

Social Security Disability Insurance (“SSDI”) benefits, in contrast, is a federal government program, and is available to most people, with certain exceptions, who have worked in any industry and contributed to the Social Security trust fund via the FICA tax.

Most ERISA plans encourage, or even require, that an employee seeking long term disability (“LTD”) benefits also apply for SSDI because any amount paid by Social Security is an offset for the insurance company, making its payments substantially less. However, being awarded SSDI benefits does not mean that the claimant will also qualify for LTD benefits because insurance companies are not bound by the Social Security Administration’s (“SSA”) determinations. Similarly, of course, the decision denying SSDI does not mean that the claimant will not qualify for LTD benefits under an ERISA plan.  But, an ERISA plan administrator is likely to use a SSDI denial as evidence that a claimant does not meet the ERISA plan’s definition of disability.

On August 16, 2019 a nationwide class action lawsuit was filed in the U.S. District Court for the District of New Jersey against the medical device manufacturer Allergan to protect women with Allergan’s textured breast implants from the increased risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), which has now been associated with Allergan’s BIOCELL textured breast implants. The case is Jane Doe I, et al. v. Allergan, Inc., et al., No. 2:19-cv-16784 (D.N.J.).

In July, The United States Food and Drug Administration (FDA) requested that Allergan issue a recall of its BIOCELL textured breast implants and tissue expanders, and Allergan agreed and is removing these products from the global market.

The FDA requested that Allergan recall all of its BIOCELL textured breast implants and tissue expanders based on newly submitted Medical Device Reports (MDRs) reporting worldwide cases of BIA-ALCL and BIA-ALCL-related deaths associated with these implants. The FDA’s “analysis was attributed to a new worldwide reported total of 573 unique BIA-ALCL cases including 33 patient deaths. Of the 573 cases of BIA-ALCL, 481 are reported to have Allergan breast implants at the time of diagnosis. In addition, 12 of 13 deaths occurring in patients with BIA-ALCL where the manufacturer was known occurred in patients implanted with an Allergan breast implant at the time of their BIA-ALCL diagnosis. The manufacturer and/or texture is unknown for the remaining 20 reported deaths from BIA-ALCL.”

We represent a number of clients who suffer from Rheumatoid Arthritis.  This often misunderstood and “invisible” disease causes extreme pain for its sufferers.  On top of the pain, many also deal with the disbelief of friends, family and employers as to the disabling nature of their illness.

Rheumatoid Arthritis (“RA”) is a chronic disorder in which the body’s immune system attacks joint tissue and causes inflammation that can spread throughout the body.  It can also cause excruciating pain.  Because there are very few visible symptoms during most stages of this disease, its sufferers appear to be fine when in reality, they are in extreme pain.

Another difficult aspect of RA, from a disability standpoint, is that there is no single test for diagnosing the condition. Rather, it is diagnosed by clinical evaluation, lab tests and imaging. This makes meeting your long term disability plan’s definition of disabled more difficult as insurers are often looking for “objective evidence” of disability.

If you suffer from certain medical conditions including Multiple Sclerosis, Complex Seizure Disorder, Dementia to name just a few, you may also suffer from cognitive impairment which can affect your ability to perform the duties of your job.  If you become disabled and make a claim for disability benefits, it is extremely important to document the cognitive impairment you suffer. Neuropsychological testing is the way to document your cognitive impairment.

If you suffer from cognitive impairment, you likely are already treating with a neurologist. He or she may order this testing as a routine part of your care.  If that has happened, you may be able to use the test results as part of the evidence you provide to your disability insurer.  If that has not already happened, we strongly recommend you get this testing done to support your claim. Note that if your neurologist orders the testing as part of your treatment and care, your medical insurance may cover the cost, which is high. If, however, you have the testing done on your own or through your attorney, insurance most likely will not cover the cost as it is forensic testing – testing to provide evidence.

Not all neuropsychologists understand the intricacies of documenting cognitive impairment to support a disability claim.  At Kantor & Kantor, we work with several highly esteemed and experienced neuropsychologists who do understand what we need to document.  They work with us to determine the which tests to conduct to best document your cognitive losses.

Seeking treatment when symptoms from mental health conditions become severe can be scary. A person experiencing paranoia, delusions, or hallucinations may not be able to advocate for themselves. They may not be able to tell doctors and nurses which medications they have adverse reactions to, how to best treat their symptoms, and who to call in case of emergencies. This may lead to them being put in situations that exacerbate rather than relieve their symptoms.

One tool that can help is a Psychiatric Advance Directive, or PAD.   A PAD is written by a currently competent person who lives with a mental illness.  The PAD describes treatment preferences and/or names a health care proxy or agent to make decisions if the person is unable to do so for themselves.

What a PAD Can and Cannot Do

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