Need help with LTD

[beaches]

What is the name of your state? New Jersey

I just found out today my appeal for LTD was denied . Back in Sept. I had knee surgery for what they thought was torn cartilidge. Well it turned out that shortly after surgery the pain spread throughout my body, I was sent to a neurologist , who diagnosed me has having fibromyalgia. I had several MRI's to rule out disc problem , MS etc. Now the insurance company is saying because these tests were normal they denied me . There is no clinical test for fibromyalgia except a "tender point" test which the Doctor does. But they keep going back to a statement that was written by the Ortho's office girl which was false. She stated I could do my job as long as I didn't stand or squat. I can't even pick up my arms most days and I spend 90% of my day on the bed with heating pads.
My question should I go for a second appeal or should I just hire a lawyer and the second part of my question is can I sue this Doctor for the untrue statements that were made from his representative ? Believe me this is causing alot of undue stress.

 

[ALawyer]

YOU HAVE ALREADY WAITED FAR TOO LONG TO GET GOOD LEGAL ADVICE. The best chance of getting benefits is before you are denied and some folk have a vested interest in proving themselves right by adhering to the original denial. Appealing on your own is likely to make the other side more adamant, especially if you do not win.

Most disability claims are denied because the claimant failed to gather -- or failed to properly present -- the kind of persuasive evidence that must be presented to enable a claim to prevail.

That's what a lawyer who does disability claims -- whether Social Security Disability or Insurance Disability -- can best do for you.

 

[ladyc4]

I second the motion to get an attorney. The second appeal does go back to the same unit, and yeah they aren't likely to reverse themselves.Appeal of 2nd denial leads to hearing with real live judge.

There are attorneys who specialize in SSD issues, they will take their fee from your back benefits-if your claim is denied they don't get paid. And SSA has a cap on the max amount attorney can charge,so there's no incentive for the attorney to let the thing drag on.

By now Fibro,and it's twin sister Chronic Fatigue Syndrome- may have become fully recognized disabilities in their own right,I think I remember hearing something about that. Do some searching on the Web, and check to see if there is a Fibromyalgia support group in your area.

I don't want to tie up this forum with a lot of detail but I've been where you are,so email me if you like.
Don't ever give up, and don't let the b*st*rds get you down.

 

[beaches]

Thanks so much to both of you

It said on the last denial letter that I need to appeal twice before I hire an attire and sue under ERISA rights. Is that correct or should I still hire a lawyer. If I do is the insurance company liable for their fee since they are if I appeal twice?
Tomorrow I am calling the ortho's office and demanding a letter from stating that the information that was submitted by his office was false. He was a dear and I hate to do this but I have to look out for my own interests now.
I would love to e-mail you ladyc4 but I don't know how to obtain your e-mail.

 

[ladyc4]

Click on my handle anywhere it appears as a link-(that means it will change color,get underlined, your cursor will change or all of the above)it will take you to a screen where you can send me an email. I tried to contact you but you don't have your email enabled.
Also I see that you are talking private insurance LTD-consulting an attorney is STILL a good idea,but getting private insurance LTD benefits depends a lot on your treating physician(s)
And you should still be able to apply for SSD once you've been unable to do any 'substantial','gainful'employment for 6 months.

 

[beaches]

ladyc4

did you receive my e-mails?

 

[ladyc4]

yes I did-glad we got that sorted out.

I gotta call it a night for now but we'll try to at least sort this thing out a little bit.

 

[beaches]

Thanks Cindy

Good night

 

[CIAA]

ladyc4,

If this is employer based LTD coverage, then welcome to the nightmare of ERISA claims. No right to state bad faith claims (except PA.), no right to trial by jury and no right to have the Court decide in your favor if it believes you are disabled. Under the law you must prove that the insurance company had no reasonable basis for their decision. Under the circumstances, if the insurer has a good qualified medical opinion on their side, you have an extreme uphill battle.

To make things worse, you can't ask for attorney fees for work done during the appeals process prior to filing suit, evidence and pleadings not made during the appeal will generally not be admitted at trial, and if you happen to win at trial the awarding of attorneys fees for work done after filing suit is discretionary and "contigency fees" will not be awarded, but only an amount that represents a reasonable hourly rate for the time spent.

I'm sorry, but if you can't build an overwhelmingly strong case during the appeals process, your chances are very slim. As ALawyer indicates, it's extremely important to get professional help early on! The "catch 22" is that since many disabled individuals are witout income, they can't afford legal help.That's is why the handling of ERISA claims have become a national disgrace.

We are not attorneys and do not give legal advice or legal opinions. Any opinions or comments in our response should not be regarded as a substitute for professional legal advice.

 

[beaches]

Thank you

I have no choice but to appeal this for a second time, this time with detailed statements from all of my Doctors concerning my condition. I am also including letters from family and friends who have assisted in caring for my daughter over the past 8 months.
I am going to make sure that all my bases are covered by these Doctors. I cannot perform the duties of my job or any other job for that matter in the state I am in.

Thanks for the insight

 

[ladyc4]

I suggest that you talk to a Social Security/Worker's Comp attorney. Is there any way that any of your problems can be work related? If you are granted SSD by the federal gov't your ins. co is going to look pretty silly saying you aren't disabled(and they still may have to pay you partial benefits to bring your monthly income up to whatever percentage of your salary or wages your insurance benefit is supposed to give you.)

 

[CIAA]

Again, welcome to the nightmare of ERISA claims.

The Federal courts have held that SSD approval means little or nothing in an ERISA disability claims dispute; that in many cases the definitions of disability are not the same and that in any event a persons' SSD approval does not, in itself, provide a current qualified medical opinion that can be used as rebuttel evidence against the insurance company's doctor(s).

 

[beaches]

It is work related

It started 4 years ago when I was under terrible stress that was documented at the time with HR. Several people quit and I couldn't take it anymore so I took a part time position. During this time I woke up one morning and I couldn't walk , I had terrible pain in my leg. So I started going to all kinds of Doctors and they were sending me for tons of tests but none of them ever said anything about MS or fibromyalgia, which I didn't even know about. After several months I finally gave up and since it was summer my leg was doing much better. But once the fall came it started up again. Well since I never had the knee MRI read because that Doctor wound up charging my insurance companies and he wound up getting paid 3 times I never went back. So that fall my g.p. had the report sent to him and he said "no wonder why you're in so much pain you have torn cartilidge". Well what did I know, so in September I had the surgery and it just got worse after the surgery, spreading throughout my body. Now they tell me that's when all this started 4 years ago. I've been told though that I wouldn't have a case against my employer? Would I?

 

[CIAA]

A claim against your employer for what?

 

[beaches]

CIAA

The stress from the situation at work caused this illness.