Denial of Short Term Disability Insurance

[majoraward]

I thought I would document in this topic what I have done so far to try to have my Short Term Disability insurance benefits paid.

I'm not going to mention names of attorneys, my employer, or the insurance company involved but I thought I would document what has happened and what I have done since then to hopefully rectify the situation. There are mistakes I may have already made but the verdict (so to speak) is not in on the outcome. I thought maybe it would be a good idea to document the steps I have taken so that others can learn from what I have done right and/or wrong in this process so that if they have a similar problem than they can see what I have done correctly, and where I have gone wrong. It will also help me so that I can look back on this as a record of exactly what I have done.

I may have to do this in several posts, maybe at the end I can put all the posts together and edit them into one final post that has all of the information. I will say upfront knowing what I know now, I am not optimistic that I will ever see a penny of my insurance benefits. If anything, maybe this post will serve as a WARNING to others who assume that the benefits they are entitled to through their insurance companies will be approved, mine were not, and they were regarding Restless Leg Syndrome.

In my next post I hope to explain what led up to my taking Short Term Disability insurance leave from my employer for RLS and what I did to apply for benefits. I also need to explain the two claim system that no one explained to me for several months, and they only mentioned it in passing.

[majoraward]

From the previous post I mentioned I would be talking about the following 2 items in this post:
1. Explain what led up to my taking Short Term Disability insurance leave from my employer for RLS and what I did to apply for benefits.
2. Explain the two claim system that no one explained to me for several months, and they only mentioned it in passing.

1. Explain what led up to my taking Short Term Disability insurance leave from my employer for RLS and what I did to apply for benefits:

I have put in for Short Term Disability 3 times over the past year [I will have to check the exact dates and update this] as a result of Restless Leg Syndrome. When I say RLS I really mean because of the lack of sleep caused by RLS. I have been in the aerospace engineering field since 1976. I have worked for several different companies and held several different postitions up until the present time. I am now an aerospace tool designer, liaision, and group checker in tool engineering.

Just to make it perfectly clear that I am not someone who goes about taking leave of absences all the time or trying to hit insurance companies for claims or something, this is the first time in all of the years (the year being part of 2011 and 2012) that I have worked that I have filed for a leave of absence, and this past year as I said I have filed for 3 short term disability insurance leave of absences for RLS, and also I am currently out on leave for having had prostate cancer surgery and I recieved my first check from the company since my current leave and the insurance company is paying me for this current leave. This tells me that it really is because of my RLS claim not going through because my cancer claim has been approved.

The first time I filed for a leave of absence my manager suggested that I do so. I had used all of my vacation and sick leave up because periodically my medications were not working well enough that I could get adequate sleep. I was augmenting, I believe, on Mirapex at the time but that is all becoming a little foggy to me now. In the first place I had not gotten very much sleep for several weeks back then making my memory then rather poor, and now to think back on it is also difficult to recall fully. I do remember that my manager was worried about me. I had told him that I was out of sick leave and vacation and yet I was so tired that I had to get home while I could or I didn't believe I would be able to drive. Also I had been nodding off at work and could not stay awake, although the restless leg syndrome would jolt me awake after only a few seconds of falling asleep. It was a terrible situation and I told him it would just be a waste of the companies money for me to sit there and occupy a seat because I was too tired to get any meaningful work accomplished.

He led me into the Human Resouces office and introduced me to them and we talked about what should be done. They told me I needed to contact the leave center via the phone and let them know that I would be out and also that I needed to see my doctor who was aware of the situation. I did everything I was suppose to do. I contacted the insurance company, I went and saw the doctor, and I had already talked to the manager and HR. I was approved to be out on short term disability for, I think it was a month, or until I could make it back to work. The short term disability insurance pays 80% of my current pay check but the first week is a waiting period and you recieve no pay for that week. As it turned out the doctor had fixed me up after only 2 weeks and I had him write a note that I could return to work early. The insurance company ended up paying for about 3 days of my leave at 80%, for some reason 2 days were not included and I didn't push it at the time, I was just glad to be back at work. So as you can see the first leave was actually approved for RLS.

2. Explain the two claim system that no one explained to me for several months, and they only mentioned it in passing:

This first short term disability insurance claim went through and I had thought that there was only one claim because that was what I had been told. The next claim I thought was also approved, and the third claim too until someone from the helpline that I talked to at my company mentioned in passing that there are actually 2 claims. I said to him something like, "What do you mean by 2 claims?" He said that the company that I work for has a claim number and the insurance company has a claim number. They are two different things. The company approved all 3 of my restless leg syndrome claims. What this meant was that they approved my time off from work, in other words I would not be fired for missing work. The insurance company claim was not approved for the remaining 2 cases. This meant that they were not going to pay me 80% of my current pay checks.

This was an important part of the puzzle that I was not told about. I kept calling up and talking to people and talking to automated machines about my claim and they kept telling me they were approved but what they were talking about was my company claim had been approved. The insurance claim was a totally different number and they had not been approved. This whole thing has been confusing and I now have maybe a 2 inch thick pile of correspondance from the insurance company, my doctors, and from my company. You would literally need to be a lawyer to be able to understand all of the information involved.

I also wanted to mention here that I was terribly sick while all this was going on. Because of augmenting I was getting virtually no sleep. I was back to pacing the floor all night into the early morning. Falling asleep literally on my feet and dragging myself up off the floor again to continue pacing. My company and the insurance company have things setup such that my wife cannot take over for me and talk to them, they won't allow it. On the other hand how much damage might I have done to my case because of this? The whole thing irratates me more than anything I have gone through in my entire life. It just is not fair to take advantage of someone who is so completely disabled, and then to deny my claims, it is just almost more than I can grasp. Before this maybe I was naive but I believed that generally that people would do the right thing. I no longer believe this and it has soured me towards even my company. My manager told me not to take it personally, but he is wrong. If the insurance company is trying to screw me over and they represent my company, then my company is also screwing me over. No matter what happens now I will be leaving my company as fast as I can, I am finished being bullied and I have had enough.

I'm finished for this evening. The next time I will explain my 2 remaining requests for short term disability. The free advice I took from an attorney who ended up not taking my case, and now I am afraid the advice he gave me about writing appeals may have been incorrect. The appeals I wrote and the denial of the appeals. If I can get to it I will finish up by explaining my quest to find an attorney that will take my case (and also why they probably will not take my case).

[majoraward]

1. Explanation of my 2 remaining requests for short term disability.

Several months later after first leave of absence the same thing happened, my medications stopped working so that I was up the entire night, every night, pacing back and forth for hours and sometimes running into walls, falling over furniture, or falling down from being so tired. My body wanted to sleep, but as soon as I fell asleep on my feet I would be jolted awake like I had put my finger in a light socket that was turned on. I remember that I continued to work for over a week of doing this. I was trying to get help from my doctor, but nothing was working.

Finally I told my manager again that I just could not function any longer, that it was dangerous for me to drive, dangerous for me to be doing liaison work in the shop, and also dangerous for me to be designing and checking tooling with virtually no sleep. The danger would be if I designed something that was dangerous to use or failed to check a job that made the tool dangerous to use. Besides it was just a waste of time for me to be at work, I couldn't think properly and that is essentially my job, to think about and resolve complex problems.

We contacted HR again and I contacted the leave center that is the insurance company that provides Short Term Disability insurance to my companies employees. This second leave I had also fell asleep the previous day on the way home from work while driving. I was in the fast lane on the freeway and woke up as I was going over the rough strips on the side of the road that were designed for the purpose of waking up a driver, it worked. If it hadn't worked I would have ended up wreaking the car in a large empty portion of rough land between the north and southbound traffic. I was very lucky to say the least. This had never happened to me before. I think the next night I thought I would be alright because I slept an hour or two so I went to work the next morning. After I got there I realized I had made a terrible decision, probably also the result of lack of sleep.

I worked about 4 hours and went home. I had thought that everything would be fine, that I was on an approved leave. A few days latter I recieved a letter saying that my leave had been approved, but like I mentioned above this was approval of the leave by my company, not the insurance company. I did not know this at the time and thought everything was fine. A couple of weeks later, about the time I was returning to work again I recieved a letter saying my leave from the insurance company was denied.

2. The free advice I took from an attorney who ended up not taking my case, and now I am afraid the advice he gave me about writing appeals may have been incorrect.

I didn't know what to do, it said I could file an appeal but I thought I should get some help. I searched the Internet and found a lawyer. I contacted his office and talked to someone and within the hour the attorney contacted me. He told me to file the appeal first and if the appeal was denied then he would take them to court. I filed an appeal and included a letter from me and a letter from my doctor that he wrote specifically for the appeal. The denial letter said I had 180 days to file an appeal and I think I filed after around 45 days. I said above that I contacted the lawyer but I think I had waited a month or so before I contacted him. I still was not doing very well and I just forgot to do it. I remember that the lawyer had asked why I didn't contact him sooner and I told him that RLS was affecting my memory. I had nothing in writing that he was my lawyer, he gave me advice and I followed it by filing the appeal.

When I sent all the appeal information I made sure that I sent it and got confirmation that they recieved the information. Several weeks later they sent me something saying they had recieved the appeal and were adding something like 45 days to make a decision.

To tell you the truth, I am not feeling very well at this moment, I don't think I am getting the sleep I assumed I was getting. Today I realized that my wife has not been including my Ambien in my nightly pills. She thought the Ambien was just for emergencies when I could not get to sleep, and that is what it used to be for but since my last sleep study just before my surgery my doctor had increased my meds to include Ambien at night because my sleep study showed that without Ambien I was not getting much sleep at night at all. I was waking up about every minute during the night. So I can only assume that this last month I have been getting very little sleep because she was not including Ambien in my nightly meds, probably really only since my last stay in the hospital on the 27th because they had been giving me additional drugs. I didn't say much to her about it today, I just said you need to include it for now on in my nightly meds. She has no idea what it actually means , I was wondering why I seemed to feel so tired, I thought maybe it was just healing from the surgery - lol - I have her take care of my meds because it would really be a mess if I took care of them, my memory is shot half the time.

3. The appeals I wrote and the denial of the appeals.

Anyway when I finally recieved the denial of the appeal I contacted the lawyer. Sent him about 10 pages of information and he ended up calling me and saying he doesn't do cases involving short term disability insurance. I couldn't believe that, he had been giving me advice and now he wasn't even going to take my case! Big mistake.

4. My quest to find an attorney that will take my case (and also why they probably will not take my case).

He sent me one lawyer's name and Internet site. I contacted them but on the site it appeared to me that they only do Social Security type claims. At the bottom of the note I said something about if they did not take these types of cases did they know any lawyers who would take my case. They answered me the next day and said they did not take my type of case but they sent me 3 names of attorneys that do take my type of case.

I wrote the first lawyer in the list and I still have not heard back from his office and it has been over a week. After a few days I wrote the next in the list, and finally the last on the list a day after. I have not heard back from any of these lawyers. I left my email address, my phone number, and my cell phone number. Nothing.

Two of the three lawyers in the list have web sites. I looked over their sites and it looked to me as if I should have waited to file an appeal until I had an attorney who would file the appeal, or at least approve what I was sending. In other words the first lawyers free advice may have ended my case before it ever had a chance to begin. I just cannot believe this. I know I should call these 3 attorneys up and talk to them or at least their office staff but I'm not going to do it. When I write I can at least try to think things out carefully, but because I am tired I just can't have a very good conversation on the phone with people. I can't orgainize my thoughts quickly enough to have a decent conversation, especially if they are going to be asking me a bunch of questions.

So I guess this is where I am at. I have sent 2 appeals in and I think they have both been denied even though my first appeal for the very same thing was approved. I have lost 2 months pay. I had expected to have the insurance give me 80% of my pay for that 2 months of time off, approved by the company. Now I have been denied that. The lawyers charge between 33% and 40% of what they would get from the insurance company, so I would be lucky to get 60% of the 80%, or roughly half of my wages for the 2 months if they were victorious (which would be better than nothing). If they aren't then there are charges I would still have to pay them that would probably be several hundred dollars. It is the principal of the thing though. The insurance company can just say no, and then that's it, you're out of luck, finished. At the most I will get half of my insurance money back. I'm tired, angry, and very mad, and there is little else I can do. If I was in tip top shape and had 100% of my brain power back I know I would be able to eventually obtain a lawyer and maybe even win against the insurance company, but after all, they are picking on a disabled person, and that is what I am a great deal of the time. I hate these people, I really do. Maybe I will get a few good nights sleep now and be able to rise up and fight again, but at the moment I just want to quit.

[majoraward]

Okay so I had given up looking for an attorney and I thought I'm going to go on YouTube and type in a search phrase and see what turns up.

Almost immediately I found exactly what I was looking for. A firm that specializes in short term and long term disability insurance claims and they are nationwide! I found their web site and filled out a brief questionaire and was sent a message to call a local number. I called them and they setup a telecom for next Tuesday. They will call me and have everyone that needs to attend be there to talk about my case. It could be that they won't take it, but this is the closest I have come to getting someone interested in it. I have gotten several more emails confirming that so-and-so will be there for the meeting Tuesday. I checked them out on the BBB and while they are not members they still have an A- rating, which is very good compared to some of the firms I have looked up.

I didn't think I would ever be excited about getting a lawyer, but I am! I sure hope it works out I would really like to get my just revenge

So I will post Tuesday afternoon one way or the other either or

ps I don't know how many times in my life that just as I have given up there is hope once again, it is fantastic.

Final thought: My wife wanted me to get some reviews on the Internet about them which I later did but she is not here right now but babysiting our 2 granddaughters at the kids house and I texted her after she texted me to get reviews the following:
"At this point I would hire a hamster if he would represent me and get my money lol"

[majoraward]

My personality is changing incredibly all of a sudden. I found an email that the attorney had sent me and actually looked at it today for the first time, no doubt my memory getting messed up again. They wanted me to send them some documents so I got together the stuff they wanted and attached it to their email they sent me and I wrote a note. Just before sending it for some reason I read their note again and the last 3 sentences as follows:

"Please understand that in order to effectively represent our clients we limit the number of cases we handle and therefore we may not be able to accept your case. We apologize in advance if we respond that we are unable to represent you with your disability claim. Please be advised that your claim may have time sensitive deadlines that must be complied with."

Here is what I wrote (I think I went a little crazy):

Actually I am not at 100% right now as I am recovering from surgery and my sleep hasn't been that great for the past several days, and I am angry. I hadn't even read this letter until today, I had forgotten about it from being exhausted, and so didn't realize I was suppose to send information until now. I'm sure it probably is a standard response that you have heard a thousand times but I'm going to say it anyway. I have worked hard my whole life and now when I become ill and need help it is denied. I had no idea that [insurance company] would deny my claim, I am finding that I am naive, I never bothered to look around and see how the world really works, I was too busy working. I am also finding that the last 3 sentences of your note below are also true, you may not be able to accept my case, I have heard it too many times in the last few weeks.

I just wallked away to go cool off for awhile because the last few sentences of your note were the last straw. I've had it, it just has made me all the more angry thinking about it. I just took the 8 documents off this email. I am cancelling our telecom for Tuesday, November 13th at 11:30 am. I won't be answering the phone. You will not be representing me, nor will anyone else, there is no one on this miserable rock who will take my case, I give up.

I had written a few paragraphs before these about what has happend with my case and then I just blew up at the end when I read what they had said. O well, better luck next time.

[Polar Bear]

Oh, I feel your anger....... and yet... regarding your comment......

I just wallked away to go cool off for awhile because the last few sentences of your note were the last straw. I've had it, it just has made me all the more angry thinking about it. I just took the 8 documents off this email. I am cancelling our telecom for Tuesday, November 13th at 11:30 am. I won't be answering the phone. You will not be representing me, nor will anyone else, there is no one on this miserable rock who will take my case, I give up.

Please do not misunderstand me but I just had to smile.......... How many times I have wanted to take that attitude over some issue.

Chin up .

[ViewsAskew]

I've read through this two or three times. Each time I am struck by how much some of us have to go through. And, how little this disease is understood.

It doesn't help us now, but in time I do believe that we will get our due. That at some point people will marvel at how we managed at all, given what we go through.

Not sure what your next steps will be. I hold hope that you find a way to fight this and get what you have coming.

[majoraward]

Oh, I feel your anger....... and yet... regarding your comment......

I just wallked away to go cool off for awhile because the last few sentences of your note were the last straw. I've had it, it just has made me all the more angry thinking about it. I just took the 8 documents off this email. I am cancelling our telecom for Tuesday, November 13th at 11:30 am. I won't be answering the phone. You will not be representing me, nor will anyone else, there is no one on this miserable rock who will take my case, I give up.

Please do not misunderstand me but I just had to smile.......... How many times I have wanted to take that attitude over some issue.

Chin up .

The last character I had on my post was a laughing smiley, I guess you can too about it, I did. The reality of the situation is that these attorneys are not going to lose even a minute of sleep over my problems, much less seek to undertand RLS/WED, especially as severe as I have it, it is just not in their nature. They are about making the big bucks the fastest way they can do it, not trying to figure out an obscure problem like mine. I just figured it out in time to fire them before getting their standard rejection form. I'll get over it, in fact I already have, let the begin!

[majoraward]

I've read through this two or three times. Each time I am struck by how much some of us have to go through. And, how little this disease is understood.

It doesn't help us now, but in time I do believe that we will get our due. That at some point people will marvel at how we managed at all, given what we go through.

Not sure what your next steps will be. I hold hope that you find a way to fight this and get what you have coming.

I'm putting this behind me and I'm not going to be looking for anymore attorneys. I just don't see how it would work out in my favor, it just is not worth it for me. If I was healthy it might be a different story, but I'm not. If I was healthy it would never have happened - lol.

As I mentioned somewhere on here before my insurance was to pay 80% of my standard paycheck so already I am losing 20% of wage. Then I found out these lawyers charge from 33% to 40% (or more) of the amount I would be awarded. My luck it would be the 40%. So then I would get 60% of the 80% - lol. So if my paycheck were $100, then the insurance was suppose to pay $80. I end up getting 60% of $80 which is $48 so that I would get 48% of my usual paycheck after having to take them to court (and I might lose because NOBODY (except those with it) understands that RLS can be a living hell).

[Polar Bear]

Yes, it is not only the physical symptoms... but how it affects every aspect of our lives. Unbelievably so... unless you are a sufferer.

[majoraward]

So the lawyer calls at 11:30 am today for the appointment, the one that I had cancelled. I did not answer but he said he would call back in 5 minutes and he was from so-and-so group. This was not the people I had cancelled with on my email. Then I wondered if they had involved somebody else in this and so when he called I answered. I said I had cancelled the appointment with so-and-so and he had no idea who I was talking about. He said that while we were on the phone together that he could talk to me about the short term disability. I let him talk away and immediately he told me something no one else had mentioned before. I knew that the insurance company was managing the short term disability for my company but what I did not know was that it was my company that paid out the money for STD, not the insurance company. So when my manager had told me that I shouldn't blame the company he was totally wrong. I don't know if he lied to me or he just didn't know, but it makes me even more angry.

He said the reason the first lawyer who gave me advice didn't take my case was probably because it wasn't for enough money. That after the appeal is denied they have to sue in federal court and because of the costs it has to be worth it for them. I sent him the denial letters because he wanted to make sure that what he was telling me was correct so I sent them. Haven't heard back yet. He basically said I would not be able to get long term disability for the same thing unless I could overturn one of the Short Term disability cases. He thought under the circumstances that I probably would need the long term disability eventually. He said that when I go back to work and if the augmentation happens again and I can't work I should immediately contact them. They will fill out paperwork for me, and especially if I get a denial of benefits. They will put in the appeal.

He said because of ERISA:

"The Employee Retirement Income Security Act of 1974 is an American federal statute that establishes minimum standards for pension plans in private industry and provides for extensive rules on the federal income tax effects of transactions associated with employee benefit plans."

that everything that they can use must be in the appeal. I had already written two appeals myself and probably messed them all up. An attorney should do the appeals to make sure that everything that is needed for the case is within the appeal. Very important. He doesn't think much of ERISA and it doesn't sound like it is on the side of the person that needs help - figures.

So if it happens again, and it probably will, then I contact an attorney and let them take care of everything. I have already used around 10 weeks of the 26 weeks allowed for short term disability so that I can still put in for short term disability, and even long term disability and they would fight to get it through for me. So we shall see, but now I don't even trust my manager. The attorney said they will take 33% of my award which is pretty standard and it could take between 270 and 365 days to go through the whole process. He was relieved that my wife has a job. I told him how over the last year it has gotten worse and the next time I augment there is no guarantee that they will ever get it going properly again, which is what my doctor basicly told me. He said also if it happens again that I should start the paperwork to get Social Security because it is also a long process of a year or two. He said I could get it at my age because it is disability through social security.

He said the long term disability would be 60% of what I make but it is not both long term disability and social security. He said that the insurance company basicly deletes their long term disability from anything I get from social security so I would not end up with a lot. I'm not totally clear about this part but the thing is that the insurance company pays as little as they can - lol.

I did not tell him about my one remaining card I will be playing Thursday, and that is my iron infusion. If that works my life would be doing a 180 percent about face and I would be healthy again. At this point in my life though I have stopped believing in fairies and the sandman - lol - and I just don't believe a miracle will be happening (oh ye of little faith) but then one never knows for sure. I tend to believe that my wild ride of 12 years will continue until I will no longer be able to work within the next year, but then I also seem to put that out of my mind most the time and pretend like health is right around the corner - lol

So that is what happened to me today. I was at an end with attorneys yesterday and ended up talking with one for a 1/2 hour today - lol - for sure I will never figure life out.

[majoraward]

The lawyer in my above post finally called me back today. He said that if it happens at work again that I will need to contact them as soon as possible and to NOT do the appeal myself. He said that because of ERISA everything that the lawyers will need to fight the case must be in the appeal. This includes at least 2 years of medical records, it includes any test I have had like sleep studies, it includes every single document about the case and anything they may need to show the judge. According to the ERISA rules the judge cannot look at anything pertaining to the case that is not in the appeal. He stressed this over and over.

He also said they might not even take my case then, it just depends on how much money they might get. They get 30% of the award but 30% of $10,000 is only $3,000. I imagine (although he didn't say what the magic number is) that it would have to involve at least 10 times that amount before I will be able to get any attorney interested. That probably would not be difficult because the last time I was out was almost 7 weeks and the doctor was just lucky that Mirapex worked because nothing else would. If I augment again I may very well never find another medication that will work. I would be totally disabled because without virtually any sleep I wouldn't be able to work again. I hate the way this whole thing works, it just is not fair. I sincerely hope I don't have to use these guys, that I will be able to work until I retire at 65 (or whatever it will be). I hate getting involved in legal crap, I want to continue to work in my profession, and I will make much more money working than at 60% disability, and even less than that because the lawyers will take a large portion.

I'm a dreamer for sure - lol. Nothing will ever be the same. How can it be unless the Iron Infusion totally works and it is already showing signs of not working when I have cut the methadone in 1/2. I am also a dreamer because how in the hell can a normal person function (me) normally taking Methadone, Mirapex, Lyrica, and Ambein everyday? My wife has to take Ambein sometimes to sleep at night and it messes her up the whole next day. There is no way she could work taking all the meds I take, I shouldn't even be working but frankly I can't afford not too. So now I just have to continue to dream and wish away the bad nights and continue along like everything is as it once was almost 13 years ago.

If it happens again though I am contacting the lawyers the first thing. I forgot to mention that the lawyer said I would be sueing my company too, that they are deep in this thing and they are the ones who would be paying my benefits for short term disability now, not the insurance company, they are just the administrators for my company. That would put another nail in my coffin to sue my company, a very big and powerful international company. It just keeps getting better and better...not.

[badnights]

Poor majoraward. Poor me. Poor all of us. (I am not being sarcastic.)
I, too, just can't accept that I'm diminished.
I want to live my life. I want to work at what I love doing, and get paid, and be respected for how well I do it.
I can't do any of those things,
and
I just
can't
accept
it

[Polar Bear]

Big group hug to all of us. (((((( hug ))))))

[badnights]

ahhhh
that feels good