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Long Term Disability Insurance and HIV
      04/15/03 01:28 AM

$13,000. Worth of advice
about group disability insurance coverage.

When I first became fully disabled and unable to work I was worried but felt comfortable in knowing that I was covered by my employer’s long-term group disability policy. I knew that this policy, (as with most group policies), promised to pay me a certain percentage of my salary should I become permanently disabled and that they would pay me these monthly benefits until I died or turned 65 years of age, (whichever came first).

As a person dealing with a permanent disability and unable to work, I continue to fight for my life on several different battle fronts. First of all there is the physical front. Anyone with a permanent disability knows about those incredible challenges. Another front is the financial one. How do you live if you can no longer work? Many of us have long-term disability coverage through our employers group plan and then there is also Social Security. You should have applied for Social Security coverage immediately when you became disabled and unable to work. The information contained in this document cost me $13,000. in legal fee’s as well as many hours of discussion with a huge variety of disability insurance professionals. I hope that reading this is of help and ultimately saves you time, frustration and money. I learned these things the hard way.

I should point out that I am writing this in the year 2003 and as you are probably aware, laws change. Keep this in mind when reading any documentation about long-term disability coverage.; that the laws change often.

I had been on long-term disability through my employer-sponsored, group disability insurance plan when the insurance company made the decision to stop paying me and sent me a “letter of denial”. If I had known then what I now know about long-term disability insurance, I could have saved myself $13,000. and I also could have caused my insurance company to pay me all of my benefits up front, there by freeing me from the monthly reporting and forms that are still required to keep my benefits flowing.

This was not the first time that the insurance company had denied my benefits. I initially filed for long-term disability benefits to my insurance carrier 2.5 years prior when my employer sponsored short-term disability benefits were exhausted. My initial claim for long-term disability benefits had been denied but I wrote a “letter of appeal” to my insurance company and this was successful in getting my initial long-term disability benefits started. My doctors were the key players here.

When I told my doctors, (medical, psychiatric, therapy), about what was happening with my insurance company, they were 100-percent on my side. They quickly composed letters in my defense which simply stated the obvious; that I was dealing with a permanent disability and that because of side effects from the drugs I took to treat my condition as well as depression caused by both the drugs and my condition, I was no longer able to work. If you do not have the support of your doctors you must get it. Without the support of medical professionals, (specifically licensed physicians), you are dead in the water before you even get started. If you have the support of your doctors then you are entering the battlefield with the most powerful weapon on your side. Be sure that you are seeing a licensed physician who is well acquainted, (specializes), with your particular disability.

As I previously explained, my long-term disability benefits through my employer-sponsored group insurance plan were cancelled after 2.5 years of steady payments and I was worried that a self-prepared, “letter of appeal”, would not be enough to get my benefits restarted. My insurance carrier secretly sent a private detective to spy on me and to film me going through my daily chores. They had film footage of me performing simple, light-duty tasks, (nothing like working), and based on this film footage and some other reasons, they once again denied my benefits.

I felt I had been accosted and I decided it was time to find a good lawyer. I did not even know what to do about the film footage and I became afraid that I was still being followed. It got so that every time I leave the house, (still to this day), I am afraid that I might be followed and filmed. I didn’t know what to do next. I searched the internet and found many, many websites about this particular subject; long-term disability insurance. Most of these websites were created and managed by lawyers who specialized in representing people in just my position. These websites were full of stories and promises. These websites, while helping to educate, are missing key points that I feel have cost me some $13,000. in legal fee’s.

Here is what I learned. I hope that it helps to save anyone time, money and frustration.

1. Unless you bought your disability insurance policy privately then it is probably governed and protected under a federal set of rules known as “ERISA” - Employee Retirement Income Security Act. These set of rules are supposedly designed to protect us, the consumer, but anyone with experience with this will tell you that these rules are designed to protect the insurance companies. It is a shelter and a “loop-hole” for the insurance companies to protect themselves against legal prosecution. I was told by my attorney’s that all of the employer sponsored group disability policies are covered under this umbrella. If you have private disability insurance then I am sorry that I have no experience so you are on your own there. If you have an employer sponsored group disability policy then read on and I hope that you will be successful in your fight armed with this information.

2. ERISA allows the insurance carriers to cancel your monthly benefits at any time and for any reason they feel justified. It doesn’t matter what your doctors say. Your long-term disability insurance carrier can cancel you at any time and deny payments for up to 180 days before you can even arrange to get a court date, (in federal court only), as you cannot sue an ERISA-covered insurance company in a state court. This means that it might be wisest to not consider hiring legal representation until after your original “letter of denial” and then again, after you have received a final “letter of denial” in response to your written appeal. I made the mistake of hiring a lawyer immediately following my third benefit denial, but only after my first “letter of denial” for this specific break in my benefits. I would have been better of if I had filed this appeal myself and then hired a lawyer after receiving my final “letter of denial” in response to my written appeal, but I was worried and afraid and I hired a lawyer too soon.

3. ERISA further requires that before you can even get a court date you must have completed a “letter of appeal” to the insurance company and only after receiving a final “letter of denial” can you proceed to court. Even if your doctor is willing to write a letter stating that your health is at risk due to the denial of benefits, it is not possible to quicken the pace of your insurance carrier’s claim processing. They have 180 days from the initial “letter of denial” in order to restart your benefits or to send you a final “letter of denial“. No amount of screaming, crying or kicking can change that. Even if you are made to become homeless and cannot afford groceries the insurance companies can take up to 180 days before they have to either pay you, (and only the amount you would have gotten in the first place), or deny your appeal. Needless to say, if you do not file an appeal then you will be denied and there is not much that you can do about that. Read your “letter of denial” carefully. Your insurance carrier must clearly state this time window in which an appeal must be received. Be absolutely certain that you submit your letter of appeal in the time frame specified otherwise you are only losing the battle.

4. This is a very important point. Examine your initial “letter of denial” very carefully. This letter is of primary importance as ERISA has very specific guidelines as to what specifically a “letter of denial” must contain. As you read through your initial letter of denial ask yourself the following;

A. What are the specific reasons for the denial?
B. Is the language of the plan referenced to the reasons for denial?
C. Does the letter explain what is required to appeal the decision or to bring you in compliance with the terms of your policy? (ie missing forms from your doctor, etc.)

If any of these things are missing then the letter of denial is considered to be in violation of ERISA policies and will give a federal judge just cause to give your case a full review - this is a good thing for you. If the letter of denial does contain all of these specific things then keep in mind that your initial appeal to this letter of denial is most important. ERISA judges normally only look at the initial letter of denial and letter of appeal, (as well as the contents of your insurance file - which you have no control over), unless a violation occurred in your initial letter of denial. If the initial letter of denial is missing any of the required information, (such as a specific reason which references the specific language of your plan), then the judges are allowed to take a complete review of your case which can include any new information from your doctors.

To review; If your “letter of denial” is missing any ERISA required language then you want to do a weak “letter of appeal” as you want to try to be given a final “letter of denial” in order to proceed to federal court - It is a good thing for you if your initial “letter of denial“ is missing the required information. However, if your initial “letter of denial” is in proper compliance with the ERISA guidelines then you want to be sure to do a most complete and strong “letter of appeal” - If the initial letter of denial is complete and contains the proper language then the judges will not let you submit any new information in your hearing.

5. Once you receive a final “letter of denial” following your “letter of appeal” it is time to hire a lawyer. Be sure to find an attorney who is specifically experienced in ERISA insurance policies. It is a very complex field. Make sure that the attorney is experienced with helping others in your situation. This is not the time to “break-in” an inexperienced trial lawyer.

In my case, my battle still continues and now I have lost $13,000. of insurance benefits to the lawyers. Unless my case eventually ends up in a federal hearing then I will be unable to recoup this money from the insurance company. In addition, since the insurance company has now re-approved me, the insurance company can again deny me, for up to 180 days, at any time, for any reason they see fit and I will be back at square one all over again. Until I have my day in court, I must continue to complete any and all forms which the insurance company decides to send to me and my doctor must continue to complete forms as often as the insurance carrier requests. The insurance carrier is free to send private detectives to spy on me and there is nothing that can be done as long as they only film me in public places.


A. Immediately request a hard copy of your long-term disability policy when you become disabeled. Request this from your insurance carrier and it is wisest to send this request with a “return receipt” required in order to further document the time and date that you made the request. Know that if you go to court, the insurance company must pay you a fine for every day that they fail to provide a written copy of the policy. This is one of the few consumer protection points of ERISA. If your insurance carrier fails to respond to your initial request for a copy of your policy then continue to request one on a monthly basis and document this well. Remember that your insurance policy is actually a binding contract with your insurance carrier. These are the terms of your contract and it is most important to get a copy of the latest policy under which you are covered. It is your insurance companies responsibility to provide you with a copy of your policy. Insurance companies revise their policies often and mostly not in the best interest of the consumer. You are covered by the policy that was in place when you became disabled so the insurance company cannot change the policy later, (as in the case of any contract - that the terms cannot be changed). When denying a claim for coverage, ERISA guidelines require that a “letter of denial” must refer back to your specific policy language when denying your benefits. Don’t let your insurance company pull any surprise punches later. Get a copy of your policy and read it.

B. Have the support of your doctors. They must be willing to complete all of the insurance carriers forms and must also be willing to write special, “letters of support”, in order to document your disability. If you have difficulty getting your doctors support then try and find a doctor who specializes in your particular disability. If no licensed medical doctor is willing to support you then you don’t have a hope.

C. Save everything. Get everyone’s name that you speak to, especially at the insurance company. Keep all documentation from the insurance company and your doctor in a well organized filing system. You will need these important documents as you proceed.

D. Be sure that your doctor lists all of your diagnosis and physical challenges on the forms to your insurance company. In addition, be sure any side effects from medications that he prescribes are documented.

E. Always be 100% truthful when describing your health challenges to both your doctor and insurance carrier. A half-truth or white-lie can cost you dearly down the road. Fortunately, I always did this but I thought it an important point to make. I did however, on occasion, under-report my symptoms and some health issues which taught me the importance of telling your doctor about all of your symptoms and not leaving anything out. Write things down as they happen if you are having memory problems.

F. If your insurance company sends you an incomplete “letter of denial” then you will be allowed to submit new information in your defense when you finally get to court. A weak “letter of appeal” is recommended in this case. It will be better for you if you receive a final “letter of denial” which will allow you to file a case in federal court. If the insurance company sends you a completely ERISA compliant “letter of denial” then you must be sure to do a very strong “letter of appeal” since if your insurance company denies your appeal and sends you a final “letter of denial” you cannot submit any new information for consideration in your case.

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* Long Term Disability Insurance and HIV Anonymous 04/15/03 01:28 AM
. * Re: Long Term Disability Insurance and HIV Jackie_Blue   04/15/03 09:40 PM

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