Disability Questions

[tommyl]

What is the name of your state? FL


My sister was on short-term disability leave from a large, well-known company. For no apparent reason, her employer arbitrarily stopped her disability payments despite supporting statements from her physicians and the company-selected physician.

Despite efforts for reinstatement and several appeals supported by statements from physicians, her payments were not reinstated. After being denied benefits for more than three months, she was severely depressed and attempted suicide.

Immediately upon being informed of the suicide attempt, her employer cut her a retroactive check for the short-term disability payments they had previously denied.

As a result of the suicide attempt, she was diagnosed with a mental disability as well as her physical disability. When the time came for her to qualify for long-term disability, her employer immediately approved her.

Eventually, she was also approved for SS Disability Benefits. SS determined that she was disabled four months prior to the time her employer had cut off her disability payments.

As of December 2002, she had been receiving SS Disability Benefits for 60 months. For that entire time, her primary health insurance carrier had been the plan provided by her employer (she pays monthly premiums). Although company policy states that after receiving SS Disability Benefits for 24 months, Medicare will become the primary carrier, she had been allowed to continue with her employer-provided carrier as her primary carrier.

As of January 2003, with no prior notification to her, her employer changed her health coverage so that Medicare is now her primary carrier and her previous carrier is now secondary. She was informed of this change, not by her employer, but by a provider after she had incurred several quite large medical bills.

With this change, her deductibles and co-pays increase considerably and her coverage for mental illness is severely reduced. She will not be able to afford the medical treatment, including psychiatric medications, that she so desperately needs. I am afraid she will become suicidal again.

I have written several letters to her employer, but I have not received any replies.

Does she have any legal recourse against the employer? Does she have any chance of getting her previous coverage reinstated?

Any help would be greatly appreciated. Thank you.

 

[cbg]

Actually, whether Medicare or the company group insurance plan is primary is not the decision of the plan administrator. It is determined by law and is based on the size of the group plan. I can never remember whether it's if the group is larger than X Medicare is primary and if it's smaller than X the group plan is primary or the other way around; nor am I positive what X is. (I think it's 20.) But whichever way it goes, it's not the decision of the group plan. They have to follow the law, and if the size of the group is such that Medicare is primary they have no control over that.

The fact that the change happened on January 1, 2003 indicates that this is the renewal date of the plan year (all changes happen on that date) and effective that date the official census of the group plan was different, changing the primary/secondary designation. (The actual change in census probably happened weeks or even month earlier, but the change in designation does not go into effect until the renewal date.)

 

[hmmbrdzz]

Hi Tommyl: You said -- Quote: With this change, her deductibles and co-pays increase considerably and her coverage for mental illness is severely reduced. She will not be able to afford the medical treatment, including psychiatric medications, that she so desperately needs. I am afraid she will become suicidal again.

I can't respond at all to the insurance stuff, but I thought I might suggest -- since you spoke about your concerns regarding her difficulty now in being able to afford psychiatric care and medication -- that you advise your sister to speak with her psychiatrist about receiving the psych medications from the drug manufacturer through the doctors office. She may very well qualify and be fully eligible to receive her psych drugs free of charge from the maker of the drug. Her doctors office will know what application she needs to fill out for this program. It would be well worth her inquiry.

Good luck.

hmmbrdzz

 

[atwitsend]

Medication assistance

Your Sister needs help for medication? User id -- hmmbrdzz is right. However, you can go straight to the source first before needing Doctor to write Meds for the Pharmacutical Co. You can find all of these Companys I am about to mention on the Net. ElderMeds (you don't have to be old), Medicine Program and try needymeds. We to have been Jerked around ever since my husband has received his Liver transplant. I too thought I was going to lose my mind and found out about these quite by accident and we BOTH qualify! Hope this helps.
God Bless You & Your Sister,
atwitsend

 

[tommyl]

Thank you

Thank you all for your responses to my message. They were all very helpful.

CBG--Thank you for the information on "Who Pays First." I did some more research on that with Medicare and found that for those who are under 65, disabled and have Medicare and group health coverage, Medicare is primary for those whose employers have less than 100 employees. The large group health plan is primary for those with more than 100 employees.

My sister is employed by a very large, very well-known insurance company so, according to Medicare, her group health plan is her primary insurer. We have received confirmation from Medicare on that point. That response is still going through the system of her employer.

Of course, it is contrary to what her employer told her; and it may mean that this very large, well-known insurance company has been "pulling a fast one" with its disabled employees and Medicare for who knows how long. As an insurance company, they surely must know the law.

Thanks again for the information.