What is the name of your state? California
I am trying to be brief, not my nature.....
Claim for LTD based on physical injury submitted 11/2002, approved 5/2003;
LTD Claim Terminated 1/28/2005; Mental Nervous Limitations (24mo);
Notice of Intent Appeal & Request for Documents - Per ERISA 4/2005; long list.
Received Administrative Record (missing some docs) 5/2005; reviewed/studied
Email Demand to Reinstate Claim based on medical records (facts) 7/2005;
** Copy of demand Cc'd to CA DOI & US DOL **
Claim reinstated; same day, Under Reservations of Rights with an accompanying fraud warning.
Are there time constraints placed on the Insurance Company in which they MUST make a determination; adverse or not?
How does one file for a 502 hearing?
The claim was originally approved as a physical injury claim. According to the Record, the claim was reviewed by an "In Hose" Physician and, based on her report, was converted to a "Mental Nervous" claim and Terminated under the policy limitations in January 2005.
A review of the Record found many irregularities and references to "Round Table" meetings, "Surveillance" assignments, and even included the psychiatric records of another individual (HIPPA).
I researched the medical aspect of the Claimant's injuries, California Insurance Laws, Codes, and Regulations, and then ERISA.
In July 2005, emails were sent out with pictures attached as a follow up to previous documentation sent via certified mail to the Insurance Company. Emails were copied to CA DOI & US DOL.
Within a few hours of the emails being sent, a "Senior Disability Benefits Specialist" called to reinstate the claim and request that no further emails be sent.
The Insurance Company scheduled an IME for August 2006. In response, a request for the doctors CV, History/Experience, and or medical publications/Research was sent with a Notice that the Claimant would videotape the exam. There was no response to the request.
Three days prior to the IME, contact was made with the doctor and the requests were made directly. The next day, the doctor called the patient to cancel the appointment, stating she was not qualified to conduct the exam.
On 9/8/2006, the Insurance Company sent a letter to advise they were scheduling with another IME physician.
They cited California Code of Civil Procedure 2032.510 to advise that NO Videotaping of the exam was allowed. Doesn't ERISA preempt this, and isn't this section for attorneys as it relates to maters of discovery?
Furthermore, a request for the "in house" physician's report was denied per 29 CFR Sections 2560.503-1(h)(2)(iii) and 2560.503-1(m)(8) stating the report was part of an "Ongoing Investigation".
What Ongoing Investigation?
I am trying to be brief, not my nature.....
Claim for LTD based on physical injury submitted 11/2002, approved 5/2003;
LTD Claim Terminated 1/28/2005; Mental Nervous Limitations (24mo);
Notice of Intent Appeal & Request for Documents - Per ERISA 4/2005; long list.
Received Administrative Record (missing some docs) 5/2005; reviewed/studied
Email Demand to Reinstate Claim based on medical records (facts) 7/2005;
** Copy of demand Cc'd to CA DOI & US DOL **
Claim reinstated; same day, Under Reservations of Rights with an accompanying fraud warning.
Are there time constraints placed on the Insurance Company in which they MUST make a determination; adverse or not?
How does one file for a 502 hearing?
The claim was originally approved as a physical injury claim. According to the Record, the claim was reviewed by an "In Hose" Physician and, based on her report, was converted to a "Mental Nervous" claim and Terminated under the policy limitations in January 2005.
A review of the Record found many irregularities and references to "Round Table" meetings, "Surveillance" assignments, and even included the psychiatric records of another individual (HIPPA).
I researched the medical aspect of the Claimant's injuries, California Insurance Laws, Codes, and Regulations, and then ERISA.
In July 2005, emails were sent out with pictures attached as a follow up to previous documentation sent via certified mail to the Insurance Company. Emails were copied to CA DOI & US DOL.
Within a few hours of the emails being sent, a "Senior Disability Benefits Specialist" called to reinstate the claim and request that no further emails be sent.
The Insurance Company scheduled an IME for August 2006. In response, a request for the doctors CV, History/Experience, and or medical publications/Research was sent with a Notice that the Claimant would videotape the exam. There was no response to the request.
Three days prior to the IME, contact was made with the doctor and the requests were made directly. The next day, the doctor called the patient to cancel the appointment, stating she was not qualified to conduct the exam.
On 9/8/2006, the Insurance Company sent a letter to advise they were scheduling with another IME physician.
They cited California Code of Civil Procedure 2032.510 to advise that NO Videotaping of the exam was allowed. Doesn't ERISA preempt this, and isn't this section for attorneys as it relates to maters of discovery?
Furthermore, a request for the "in house" physician's report was denied per 29 CFR Sections 2560.503-1(h)(2)(iii) and 2560.503-1(m)(8) stating the report was part of an "Ongoing Investigation".
What Ongoing Investigation?