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ERISA plan changing the rules

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Str87daze

Junior Member
What is the name of your state? KY

Here's my sisters story. " I am disabled and have been since 1998, I had a first review in 2001 in which I was submitted to an FCE, benefits terminated, I appealled and got benefits back. Recently, I was again told to take the FCE. I did so, and of course, they said the same thing-that I can do a sedentary job...my rhematologist and PCP disagree, and stated so. however, the insurance company had me followed-not really a big deal as I am not working. They sent my doctors a misleading package stating in the cover letter that I was doing thing in a video that I lied and said I could not do, that I was working at a company that they claimed I owed, and many other things. One doctor told me to come look at the stuff as he said when he closely looked at the material it was clear that I was not doing anything that was not disclosed to my doctors, and wrote them a letter telling them that their cover letter was misleading.

When I picked up the pack, I was amazed. the claims lady tried to say that picking up my newborn infant was something that I said I could not do. I never stated that. I have always been firm that I am capable of doing most activities for a period of time, it is the effect that it has on me. I get sick from most activity-full blown flu like illness that puts me out for days at a time. This carrying of an infant was only to get him out of the car and put him in a shopping cart-in his carrier, so I didn't have to carry him but a second. In her narrative she said that I was 'leading a full, activity lifestyle that was in direct conflict with the information I provided to my doctors'. After looking over everything, I saw that they actually sent me someone elses letters as well-surprise, surprise-hers said almost the same thing substituting that she had a mental condition v a physical one. The investigator that they hired did not say that he ever saw me working any of the days that he followed me out of my house. He said that he assumed that I owed the business (my husbands) and he told some actual lies in his report. SOme of the times that he said I was in one place, I was at PT and that can be proven. He said that my husbands employee told him that I worked there on certain days and that I did jobs such as payroll. My husband didn't even have a payroll and no employee. That guy was a friend standing in while my husband cut grass. THe friend gave me a written statement before he joined the military. Oh, the real kicker was that he claims to have spoke to me on the phone and that I answered my husbands biz phone stating my name, and he said that I was very knowledgable about a product that doesn't even exist. He also claimed to have made an appointment for some service work, but for some odd reason, he didn't come in to catch me on film. Surely if the conversation took place like he claims he wouldn't have missed his only opportunity to prove I was working. ANyway...

finally i get a notice stating that they are termination my LTD. when i request the records for prep of my appeal, i find that all their doctors used the lies and misinformation that was summed up by the claims agent in her report as a basis of their medical diagnosis that I could work. They did not mention the fact that I had been receiving benefits since 1998, and my condition has not only not improved but worsed with added diagnosis'. By the way, I have fibromyalgia, degenerative disc disease neck and low back, Thoracic Outlet compression, cubital tunnel, A previous spinal fracture, dermagraphic hives daily from stress and fatigue, and a narcoleptic condition. I have tried (believe this was not my dream life) to do school, but continued to get sick from sitting in class a few hours (with phlegm, coughing, sore throat and fatigue). I also get unbearable chest wall spasms in which I can not breathe and have horrible pain trying to get the meds down the pipe when this happens. I get no stage 3,4 or Rem sleep. All of that was ignored. None of their doctors claimed that I was better than the last review, only that I could work.

Well, I got my letter of termination. It said that I had so many days from the day that I recieved the letter to file the appeal. I did so with time to spare, but they claim I was late and refused to review the appeal. Here is the basis-they didn't send the letter certified or signature required. They sent it through a package carrier, who left it with a man. They did not get a signature, they only recorded that it was a man. That man was a friend sitting on my porch waiting for me to come home so he could pick up some used magazines. Well, I didn't go home, so my mom gave him the magazine and he inadvertently took the package home. He forgot and gave it to me some time later. I told the claims person this and he provided a signed affadavit as the date that I received the letter is not the date that she claims I received it, which is when the delivery guy left it. Still she is refusing to review it even though by the terms of the letter, I am in compliance.

How long do I have to file a lawsuit? This is an employer paid plan so I know it is an ERISA claim, but I can't find any lawyers in my town who do that kind of law. And last question, if the claims agent and the investigator conspire to lie with malicious intent to get their doctors to say I can work, are the investigator and the agent protected by the ERISA plan? The investigator is a hired contractor so can he be sued in state court? If the agent is acting outside the scope of her employment-in lying as I presume the insurance co will not admit that is part of the job, can she be sued in her individual capacity in a state court?'

Sorry so long, but she is Long winded.
 


briannamc

Junior Member
Erisa

I hate to hear that. The DOL and lawyers have pretty much told me that Erisa law is worthless unless you can nail them good. Trust me, the LTD company and their incompetent medical staff are against you. It is a total game to them. Laws don't matter to them. I am in a similar situation and that is the reality. Suing takes up to a year (then longer if they appeal which they probably will do). Why do they do it? To discourage people from getting benes. My STD/LTD company even violated Privacy laws and revealed my condition to my employers. The only thing I can recommend is get a damn good lawyer not intimidated by possibly years of litigation before you see a penny.
 

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