Give me my money back, give me my money back-you bitch.

June 16, 2009 8:00 AM

How do I appeal a long term disability claim that's been denied?

I worked as a retail manager until this past February when I had a major hernia repaired. Because of the location, the type of repair that was done and complications I had with the surgical wound, my doctor has put me on "light duty" until the end of August. I have long term disability insurance, but they refused to pay anything after April 30th. In my particular job, I am required to work alone at times for up to 4 hours, I process shipments which come in boxes up to 75 pounds, I regularly move full tables of products and carry bags of products that weigh up to 30 pounds. In addition, I climb ladders which requires balance that I don't have anymore (per my surgeon) because the muscles that were repaired are my core abdominals which are responsible for balance.

The LTD company states that the reason they are denying further payment is because according to my "occupation" I don't require lifting. They further state that whether my "job" requires it or not isn't relevant, they go by occupation when making their decision. I told the case manager I wanted to appeal the decision, because I am unable to go to work until my surgeon releases me (he won't) and because I can't perform my job requirements I would be fired for incompetence (a technicality, but they have to have someone that can do the full job and I can't).

I had to request the appeal paperwork twice and received the 2nd set yesterday. Basically it was just a letter detailing their reasons for the denial and if I wanted to appeal, to call their 800 number. Obviously, that's been done several times over. I've left a message for the case manager to ask her exactly HOW to appeal this, but she hasn't returned my calls yet. I'm lost as to my next step since I really feel that this is just standard for them to deny as a matter of routine. (This is after they took nearly 7 weeks to determine it wasn't a pre-existing condition.)

posted by hollygoheavy to work & money (11 comments total)

What is the name of the insurer and the policy?

Your policy should contain the details on how to appeal.

They may actually be right, not being able to lift does not seem essential to an occupation of "retail manager." You really ought to consult with a lawyer here, fighting their own definition of requirements might be quite difficult. Failing that, you should consult with a lawyer on whether your employer can really fire you for temporarily being unable to carry out job responsibilities that seem like they would reasonably be able to accommodate.
posted by grouse at 8:14 AM on June 16

Yeah, lawyer up. Without the ability to consult your disability insurance policy's declarations page or knowing the relevant law in your jurisdiction, this isn't a question anyone here is going to be able to answer. Even if we had that information available, no lawyer is going to give you advice here, because that'd be a pretty major violation of ethical rules. They also aren't going to do it for free.

But even if none of those things were true, your next step would be to consult a lawyer anyways. If your income is low enough, you might qualify for legal aid. It's worth looking into.
posted by valkyryn at 8:23 AM on June 16

Lawyer.
posted by jefficator at 8:34 AM on June 16

When clients of mine have disability claims denied I refer them to legal aid for the appeal. Your income has to be pretty low to qualify for legal aid, most of the clients I have referred who got representation on disability appeals were homeless at the time. One client who retained a private attorney for a disability appeal was able to do so on a contingency basis, with the lawyers fees to be drawn from the lump sum back payment if the appeal was successful.
posted by The Straightener at 8:35 AM on June 16

Thanks everyone for the advice. In the grand scheme of things, the amount of money we're talking about probably is less than what I'd pay a lawyer.

Grouse-retail management is lots and lots of lifting and moving products around (I worked for a chain that sold shower gels and lotions and accessories), as well as having to reset the store every 3 weeks. It does seem like retail is a lot of standing around and trying to talk people into spending money, but the behind the scenes stuff is pretty physical.
posted by hollygoheavy at 8:47 AM on June 16 [1 favorite has favorites]

hollygoheavy, I understand what you are saying but it seems like that is probably a feature of your job rather than your occupation as well. I'm guessing your occupation would be closest to "First-Line Supervisors/Managers of Retail Sales Workers" which the Bureau of Labor Statistics says "Directly supervise sales workers in a retail establishment or department. Duties may include management functions, such as purchasing, budgeting, accounting, and personnel work, in addition to supervisory duties." Nothing in there about manual labor. And I daresay there are retail management jobs out there where there is not manual labor involved, even if in many of them there are. And that your employer should be able to accommodate you by allowing you to direct others in the manual labor without interfering with the core nature of your occupation.

Anyway, I put this to you not to argue with you but so that you can understand (a) how your insurance company's argument works and (b) how difficult it will be to convince them otherwise without help.
posted by grouse at 8:59 AM on June 16

In the grand scheme of things, the amount of money we're talking about probably is less than what I'd pay a lawyer.

As The Straightener said, lawyers might take this case on contigency, an arrangement where you pay nothing if you lose and a portion of your settlement (typically 1/3) if you win. One advantage of this is that, in both your interest and theirs, the lawyer will make an educated guess at the likelihood of a successful suit. If they think you don't have a case, they will be honest about it rather than suck you dry.
posted by randomstriker at 10:47 AM on June 16

What randomstrikersaid. And if you're a member of a union, like Retail Clerks, the union may have referrals to local lawyers who represent union members in cases such as these against the insurers. You might also want to contact your state disability office as they'll be able to guide you through the procedure to file a Social Security Disability Insurance claim if you qualify. In California, where I live, they're called the EDD (Employment Development Department). In Florida, where your profile indicates you're from, they're called the Division of Disability Determinations. Not to discourage you, but I've yet to meet a person who has filed a successful claim with either their employer's disability insurer or for SSDI without a lawyer. So get a lawyer, ASAP. It will still be a long, arduous process, but a lawyer can help you navigate the system and increase your odds of success.
posted by LuckySeven~ at 6:09 PM on June 16

Grouse- thanks for explaining the difference between occupation and job. I agree that there are retail management jobs that don't involve anything more than pushing papers, however I work(ed) in a small boutique style store rather than a dept store, where the managers were often the only employee for 4 hours at a time in the store. Your explanation really helped me understand how the company came to their decision.

I'm looking into the Division of Disability Determinations, so thanks for that LuckySeven!
posted by hollygoheavy at 4:37 AM on June 17

You might be able to return to work with a reasonable accommodation. Major hernia with complications could well be a "disability" under the ADA Amendments Act.

If not, I would keep appealing -- get the paperwork or the instructions. There will be some kind of process. Look closely at the language of your policy and try to match your medical situation to the language. Talk to your doctor. If you want to speak to an attorney you are looking for an ERISA plaintiffs attorney.
posted by ClaudiaCenter at 10:51 PM on June 18

Holly - your right to appeal is governed by ERISA. Essentially, you have the right to appeal the closure decision. Get a copy of your Summary Plan Description from your employer (it is their responsibility to provide it). Go through it and look for the section called "CLAIMS". There will be a clause called Decisions or some such. Generally, it will tell you that you have the right to request a review in writing and you will be notified of the decision within 45 days and so on. You have an opportunity to submit information in support of your claim.

If they are ignoring you or it feels like you are getting the run around, send a certified letter. The Department of Labor clock starts ticking on the day they receive the appeal request. They have 90 days total (two 45-day periods) to review the original decision. After that time period expires, if the review has not reached a conclusion, you have the right to sue.

Good info, grouse. Likely, Holly, your occupation, as classified by the Dictionary of Occupational Titles, is considered to be light, which involves lifting up to 20# occasionally. So, as you policy is most likely worded, you are possibly disabled and unable to perform your own job (which sounds like it is DOT medium), but your own occupation definition of disability is unmet.

Unfortunately, as is often the case, most folks have an idea of what they’d like their insurance coverage to be, but the reality is that true coverage detail is somewhat different. After you have suffered a loss, it is too late to go back and make appropriate changes. It does not do much good to blame the insurance company, either. Unless they have a history of being fined, they are likely operating as the law allows. And the law is not unfairly tilted in their favor – it is fair to all parties. No benefit in grousing about that, either.

Your best bet, in every situation, is to protect your interests, which is generally referred to “lawyering up”. Scare quotes are intended here. Be very careful who you choose to represent you because, in my experience, lawyers who practice in this field are largely incompetent. They rely on two factors: 1) the inefficiency & propensity towards mistakes of a bureaucratic organization (scavenger/scamming behavior) and 2) the fact that often times it is cheaper to settle out of court than to dispute an illegitimate claim (blackmail behavior), which, although is perfectly legal and, apparently ethical, for lawyers to do these things, for you and me we’d be put in jail.

Gosh, I really tried to not editorialize. I hope this answer helps.
posted by valentinepig at 8:57 AM on June 27