Ltd Benefits Terminated

[cozyheart]

What is the name of your state? New York, NY

I have been receiving LTD benefits since April 1998. The insurance carrier provided legal assistance in helping to file for Social Security, which was approved. The insurance carrier has now deemed that I am no longer disabled under the plans definition. They have done this several times before, whereupon appealing, I was reinstated. I believe I now need legal advice. However, my income is severely limited. Are there any organizations or advocates who do pro-bono work, offer discounted rates or nominal payment plan?

 

[CIAA]

Cozyheart, is this an individual policy or employer group regulated by ERISA? This is going to make a big difference.

 

[cozyheart]

LTD Benefits Terminated

It is a group policy provided by my employer, no contributions to the policy were made by me.

 

[CIAA]

Well then, I'm assuming that your plan falls under Erisa and therefore the State Board of Insurance won't have enforcement authority, the Dept. of Labor does and you should file a complaint with them. While recent amendments allow certain individuals to file suit at any time, it is for disability claims filed after 1/1/2002 and I have not seen any interpretation on whether a "continuing claim" after 1/1/2002 can qualify. Therefore you are probably going to have to go thru the appeals process. The good thing is you have been successful at the appeals process before. Needless to say, a lot is going to depend upon whether or not your condition has improved, what your doctor says and what their doctor is saying.

 

[cozyheart]

The Insurance Carrier has never sent me to a doctor. They only requested a Functional Capacity Evaluation (FCE). My doctor urged me not to have the test. However, I had no choice, if I didn’t take it my benefits were going to be terminated for failing to comply with plans provisions. The FCE results state that I can perform sedentary work. My doctor disargrees with these findings and has written them a letter to that affect. They said a Board Certified Gastroenteroligist reviewed my files of past MRI's, Surgical notes, physician statements, and surveillance video, and he believes I am no longer disabled by plans standards. This is the second FCE that was requested of me and the results are the same, my condition has not improved, if anything it has gotten worse. The first FCE stated the same thing that I was able to perform sedentary work. It also went on to say that if I got a good pair of walking shows I could push dead bodies around. I was never so insulted. I guess I’ll write a letter, get the most recent test results and physician’s notes and request an appeal. Not clear on what my next step would be if this appeal isdenied.

 

[Beth3]

Your LTD Plan Document/insurance booklet should outline steps to appeal the carrier's decisions - that information is probably in the very back of the book. Typically, the first step is to file an appeal in writing with the carrier. If that is denied, the next step is usually to file an appeal/complaint with your State's Insurance Commission. If that fails, then you'll need to obtain legal representation.

 

[cozyheart]

Legal representation is what has me concerned. Considering my income is severely limited and the insurance company has deep pockets which will afford them the luxury of dragging this out for ever. There is no way I can afford to retain a lawyer.