Articles Tagged with insurance denials

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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?

Many employers today provide group life insurance coverage for their employees. A benefit adjacent to group life insurance is accidental death and dismemberment (“AD&D”) insurance. AD&D insurance pays you a benefit if you lose a limb or an eye, or it may pay your beneficiary additional life insurance benefits if you die in an accident.

Most AD&D policies define accident with terms like “sudden,” “unforeseeable,”  “unintentional,” and “external cause” – not exactly concrete and easy to follow guidelines to determine whether a death was accidental or not. When a claim is made to an insurance company for accidental death benefits, the insurer considers the events and actions that caused the person’s death and decides whether the claim meets the policy’s definition of accident. If the death was caused by an injury and not an illness, how did that injury happen? Was the person going about their normal life and was struck down in some way that they did not expect? Were they doing something dangerous and likely to cause injury? As one judge said: “What is an accident? Everyone knows what an accident is until the word comes up in court. Then it becomes a mysterious phenomenon, and, in order to resolve the enigma, witnesses are summoned, experts testify, lawyers argue, treatises are consulted and even when a conclave of twelve world-knowledgeable individuals agree as to whether a certain set of facts made out an accident, the question may not yet be settled, and it must be reheard in an appellate court.” Brenneman v. St. Paul Fire and Marine Ins. Co., 411 Pa. 409, 192 A.2d 745, 747 (1963)

The decision of whether a death was an accident often hinges on whether the person’s death was “foreseeable.” When analyzing whether a death was foreseeable, the insurer generally first considers whether the person expected to be seriously injured as a result of their actions. Consider a scenario where a person died when they were injured diving off a tall cliff. If that person was a champion cliff diver and regularly dove off tall cliffs, they would not expect to be seriously injured performing such a dive. Second, the insurer considers whether that expectation was reasonable. In the case of our cliff diver, because she had been cliff diving regularly without injury, her expectation to not be injured while cliff diving was reasonable. This analysis becomes more confused in the real world where the facts are not always so clear.

Lipedema is a condition that causes excess fat to accumulate in the lower part of the body. Lipedema most often involves the buttocks, thighs, and calves. The upper arms can also be affected. The condition does not affect the hands or feet. It can also lead to debilitating symptoms if left untreated, including chronic pain and the inability to walk or move around easily.

What Causes Lipedema?

The exact cause of lipedema is unknown. But the condition runs in families and may be inherited. The condition occurs almost exclusively in women, and usually starts or gets worse at the time of puberty, pregnancy, or menopause. Because of this, there is likely a connection to hormones. Lipedema is not caused by obesity but more than half of patients with this condition are overweight or obese.

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.

Here at Kantor & Kantor, we like to refresh and give updates to certain parts of the process we use to help individuals. We feel that the more people understand their insurance benefits, the better they will be able to fight when benefits are denied. Long-term disability (LTD) insurance is a large part of this process, so we will explain the basics here.

Long-term disability insurance is an insurance policy that protects an employee from loss of income in the event that he or she is unable to work due to illness, injury, or accident for a long period of time.

LTD can provide benefits for work-related accidents or injuries that are covered by Workers’ Compensation insurance, but there usually will be an offset, where the LTD benefit is reduced dollar-for-dollar by the amount of Workers’ Compensation payment. LTD also does cover an employee in the event of a personal accident such as a car accident or a fall.

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.

Dealing with insurance companies can often feel complex, challenging, and overwhelming. You are not alone. But it is always best to understand your mental health benefits BEFORE you need to use them. Mental health services may be covered in whole or in part by your health insurance or employee benefit plan. It is important to understand your mental health benefits as you will be responsible for any unpaid claims.

Here are some tips and questions to consider as you try to understand your mental health benefits.

  • Obtain a copy of your health insurance policy or employee benefit plan.

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.

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