Congress won't help disabled American
Preston Goldstein
June 30, 2009
There are millions of disabled people who have been dropped from their long term disability policies by insurance companies because under the federal law "ERISA" Insurance companies can decide that a person is not disabled without supporting their claim with ALL the medical facts, just the ones that prove their point, while ignoring the main points that prove the person REALLY IS DISABLED.
This is about the pitfalls of long term disability insurance and how hard it is to actually collect for the full life of the policy. Long term disability is controlled by federal law under ERISA, and has many loop holes for insurance companies to get around it. A federal judge must use the "standard of review" which the disabled only win if the insurance company was "arbitrary and capricious" in their decision, which means, as we were told by lawyers, the insurance company can interpret the medical records as it wants and can conclude if the party can work, ignoring any fact that show they can´t work and using parts or medical reports taken out of context that by their standards show the person is disabled. This means the facts that show a person is disabled are not in presented, just what the insurance company wants known so they were not "arbitrary and capricious" in their decision. Many people have disability insurance and are not aware of the pitfalls and tricks the insurance companies use to deny benefits, or that any workman compensation or other forms of disability claims "INCLUDING SOCIAL SECURITY" will be deducted from the amount of payment the insurance company is required to pay on the policy. Something needs to be done to change this law which control how legal appeals of denial are performed.
In this case the insurance company , who has projected a $920 MILLION profit from its health and disability insurance policies.
We all know the increasing cost of health insurance is on the rise as the company´s claim their costs are soaring, but looking at the profit how do they justify the increases.
Someone needs to investigate the law "ERISA" which regulate these companies and stop them from using this law to deny policies by ignoring the facts since what they write is what the judge reviews. The "security blanket" of disability insurance people are expecting is not what they will be getting. If I was not married and this happened I would have to be on welfare just to get by, since what I thought was protection from this is not what I expected to receive but is a real horror story. We are sold these policies, with the words "you will receive XX% of your income if you become disabled for as long as you can not work at that job. Most policies after 2 or 3 years change to any job that the insurance company feels you are qualified (even if you are not) and can then stop payments. People see disability insurance as a way to get by, since they may have additional income from other sources (social security disability, workman comp etc) as a way to get by, but these other sources will be deducted from the payment they get by the insurance company, which is NEVER explained when they are being sold, and the companies can state if you don´t file for these added income sources, they WILL not pay on the policy. Further most companies do not distribute the policy to their employees.
Do you think these companies should be able to use FEDERAL funds from Social Security, which we are forced into paying into, to subsidize their insurance policies and therefore increase their profit?
The government should force these companies to either pay back into Social Security (refinancing the plan) the funds they deducted from their policies, or pay the people who had the policy what was deducted.
Also the standard as to whether a person is disabled should not be allowed to rest with the insurance companies as they are trying to prove the person is not disabled so they don´t have to pay them. A federal agency should be the judge of that, and since Social Security already does that then a person collecting Social Security disability should therefore be declared "DISABLED" for all insurance polices removing any conflict of interest.
The law NEEDS to be changed for the disabled and those that filed law suits and were basically denied should be granted new hearings if they at the time were collecting Social Security disability.
Below this is my wife story and it is all too familiar for, millions of other disabled persons.
This is her story which needs to be told, please change the laws so these insurance companies will do to payout the full policy.
My wife is disabled, and currently collects Social Security disability, which was awarded without a fight. She was collecting disability insurance from the insurance company until the "2 year rule" which stated that if she can hold down any job they decide she is no longer disabled.
She had chronic deterioration of the knees and her doctor said she had to sit for 50% of the day and her employer "store a" said that was not acceptable so she went on long term disability from "store a". First thing the insurance company did was call her for an interview and threaten her with arrest if she was lying about her medical condition. Once they decided she was disabled under "store a" policy, she then was informed she "must" file for Social Security disability otherwise they would not pay her on the policy. Once she qualified for Social Security disability, the insurance company started deducting that amount from what they were paying her, allowing federal funds to supplement their payments. While on disability during the first year she had double knee replacement as her knees were totally giving out. At the end of her second year on disability the insurance company sent out physical assessment forms for her doctors to fill out. On these forms both of her doctors stated she could not sit for greater than 2.5 hrs in the 8 hr working day, or stand for the same.
the insurance company found 2 jobs (from the) that they claim she could do that required by their definition of "sedentary" sitting most of the 8 hr day (these jobs may not exist in real world or no openings may be available even if they exist. Also she never did these jobs and has no experience at these positions and both jobs require experience. the insurance company has stated she could not challenge these jobs based on experience or training (one of these jobs was as an information clerk giving walking tours).
the insurance company determined she could work and 2 days before the end of the second year they informed her they were dropping her and she could appeal with medical reports but not appeal on grounds she was not qualified for the jobs based on experience.
the insurance company was sent doctors reports from her primary doctor and her rheumatologist which stated that upon sitting for approximately 2 hrs her feet swell and become painful and she needs to lie down and elevate them until the swelling goes away.
the insurance company´s independent doctor´s report determined she was perfectly capable of working an 8 hr day 5 days a week the insurance company´s doctor (who never saw her, ignored the swollen feet and substituted "sore feet" and said she should get up and walk around to relieve the stiffness. Another Doctor who has seen her wrote that her knees are still very stiff and painful and she could not hold down any job. the insurance company´s doctor ignored this report. Also this "independent doctor" was sending draft copies of his report to the insurance company for their review.
In the insurance company´s final refusal letter there were many errors about what happened and their denial made no sense. They stated she left "store a" due to her diabetes, which she did not have at that point, and she left due to degenerating knees. They then spent 2 paragraphs detailing why she could work with diabetes ignoring the real reason and at no time did they refer to her swollen feet which were the main reason she is disabled at this time.
the insurance company the informed her that her appeal was denied and she could take legal action under "ERISA". Also she could send further medical reports (within180 days) indicating she was not capable of working. She hired a lawyer who sent her to a specialist on employment capability and this report was sent to the insurance company and of course denied as valid. The lawyer had to file the complaint in federal court since the controlling laws were ERISA and then a federal judge would determine which side was correct. We were told that the judge would decide based on "rule 41" uses a standard of proof being that the insurance company was not " arbitrary or capacious", and we were told by our lawyer that meant a "killer decision" meaning whoever was favored won. the insurance company the insurance company petitioned the court for a lock down date of the refusal letter, even though there was another doctor´s report submitted after this date as allowed in the denial letter. The judge rule the lock down date was the date the insurance company requested. A meeting to set the guidelines was set and during this meeting the judge said he was ruling for the insurance company and would not hear from her lawyer what was not correct or missing from the insurance company´s doctor. We were informed that we could appeal within his decision within 90 days otherwise we would receive a settlement of $8500 minus lawyers fees ( on a policy that already had over $7000 in back pay and potential of additional $31000).
Part of the deception of the insurance company is their settlement release form which I never signed and I never agreed to this settlement. In it there are non disclosure paragraphs throughout with threaten a person and its family with financial ruin should they break this settlement. Also threats if the news media was ever told of what happened. They also state that the claimant agrees she was not disabled ( she would NEVER sign anything link this) and they are not held accountable for anything even breaking a law or other reasons why they were wrong in termination of her.
I have documentation of this and everything else written in this letter and if you are serious about helping me I will gladly send copies to you
Please help the poor disabled people who depended on these insurance policies to be able to have a quality of life, by changing the laws so the insurance companies will have to payout the full policy.
This is about the pitfalls of long term disability insurance and how hard it is to actually collect for the full life of the policy. Long term disability is controlled by federal law under ERISA, and has many loop holes for insurance companies to get around it. A federal judge must use the "standard of review" which the disabled only win if the insurance company was "arbitrary and capricious" in their decision, which means, as we were told by lawyers, the insurance company can interpret the medical records as it wants and can conclude if the party can work, ignoring any fact that show they can´t work and using parts or medical reports taken out of context that by their standards show the person is disabled. This means the facts that show a person is disabled are not in presented, just what the insurance company wants known so they were not "arbitrary and capricious" in their decision. Many people have disability insurance and are not aware of the pitfalls and tricks the insurance companies use to deny benefits, or that any workman compensation or other forms of disability claims "INCLUDING SOCIAL SECURITY" will be deducted from the amount of payment the insurance company is required to pay on the policy. Something needs to be done to change this law which control how legal appeals of denial are performed.
In this case the insurance company , who has projected a $920 MILLION profit from its health and disability insurance policies.
We all know the increasing cost of health insurance is on the rise as the company´s claim their costs are soaring, but looking at the profit how do they justify the increases.
Someone needs to investigate the law "ERISA" which regulate these companies and stop them from using this law to deny policies by ignoring the facts since what they write is what the judge reviews. The "security blanket" of disability insurance people are expecting is not what they will be getting. If I was not married and this happened I would have to be on welfare just to get by, since what I thought was protection from this is not what I expected to receive but is a real horror story. We are sold these policies, with the words "you will receive XX% of your income if you become disabled for as long as you can not work at that job. Most policies after 2 or 3 years change to any job that the insurance company feels you are qualified (even if you are not) and can then stop payments. People see disability insurance as a way to get by, since they may have additional income from other sources (social security disability, workman comp etc) as a way to get by, but these other sources will be deducted from the payment they get by the insurance company, which is NEVER explained when they are being sold, and the companies can state if you don´t file for these added income sources, they WILL not pay on the policy. Further most companies do not distribute the policy to their employees.
Do you think these companies should be able to use FEDERAL funds from Social Security, which we are forced into paying into, to subsidize their insurance policies and therefore increase their profit?
The government should force these companies to either pay back into Social Security (refinancing the plan) the funds they deducted from their policies, or pay the people who had the policy what was deducted.
Also the standard as to whether a person is disabled should not be allowed to rest with the insurance companies as they are trying to prove the person is not disabled so they don´t have to pay them. A federal agency should be the judge of that, and since Social Security already does that then a person collecting Social Security disability should therefore be declared "DISABLED" for all insurance polices removing any conflict of interest.
The law NEEDS to be changed for the disabled and those that filed law suits and were basically denied should be granted new hearings if they at the time were collecting Social Security disability.
Below this is my wife story and it is all too familiar for, millions of other disabled persons.
This is her story which needs to be told, please change the laws so these insurance companies will do to payout the full policy.
My wife is disabled, and currently collects Social Security disability, which was awarded without a fight. She was collecting disability insurance from the insurance company until the "2 year rule" which stated that if she can hold down any job they decide she is no longer disabled.
She had chronic deterioration of the knees and her doctor said she had to sit for 50% of the day and her employer "store a" said that was not acceptable so she went on long term disability from "store a". First thing the insurance company did was call her for an interview and threaten her with arrest if she was lying about her medical condition. Once they decided she was disabled under "store a" policy, she then was informed she "must" file for Social Security disability otherwise they would not pay her on the policy. Once she qualified for Social Security disability, the insurance company started deducting that amount from what they were paying her, allowing federal funds to supplement their payments. While on disability during the first year she had double knee replacement as her knees were totally giving out. At the end of her second year on disability the insurance company sent out physical assessment forms for her doctors to fill out. On these forms both of her doctors stated she could not sit for greater than 2.5 hrs in the 8 hr working day, or stand for the same.
the insurance company found 2 jobs (from the) that they claim she could do that required by their definition of "sedentary" sitting most of the 8 hr day (these jobs may not exist in real world or no openings may be available even if they exist. Also she never did these jobs and has no experience at these positions and both jobs require experience. the insurance company has stated she could not challenge these jobs based on experience or training (one of these jobs was as an information clerk giving walking tours).
the insurance company determined she could work and 2 days before the end of the second year they informed her they were dropping her and she could appeal with medical reports but not appeal on grounds she was not qualified for the jobs based on experience.
the insurance company was sent doctors reports from her primary doctor and her rheumatologist which stated that upon sitting for approximately 2 hrs her feet swell and become painful and she needs to lie down and elevate them until the swelling goes away.
the insurance company´s independent doctor´s report determined she was perfectly capable of working an 8 hr day 5 days a week the insurance company´s doctor (who never saw her, ignored the swollen feet and substituted "sore feet" and said she should get up and walk around to relieve the stiffness. Another Doctor who has seen her wrote that her knees are still very stiff and painful and she could not hold down any job. the insurance company´s doctor ignored this report. Also this "independent doctor" was sending draft copies of his report to the insurance company for their review.
In the insurance company´s final refusal letter there were many errors about what happened and their denial made no sense. They stated she left "store a" due to her diabetes, which she did not have at that point, and she left due to degenerating knees. They then spent 2 paragraphs detailing why she could work with diabetes ignoring the real reason and at no time did they refer to her swollen feet which were the main reason she is disabled at this time.
the insurance company the informed her that her appeal was denied and she could take legal action under "ERISA". Also she could send further medical reports (within180 days) indicating she was not capable of working. She hired a lawyer who sent her to a specialist on employment capability and this report was sent to the insurance company and of course denied as valid. The lawyer had to file the complaint in federal court since the controlling laws were ERISA and then a federal judge would determine which side was correct. We were told that the judge would decide based on "rule 41" uses a standard of proof being that the insurance company was not " arbitrary or capacious", and we were told by our lawyer that meant a "killer decision" meaning whoever was favored won. the insurance company the insurance company petitioned the court for a lock down date of the refusal letter, even though there was another doctor´s report submitted after this date as allowed in the denial letter. The judge rule the lock down date was the date the insurance company requested. A meeting to set the guidelines was set and during this meeting the judge said he was ruling for the insurance company and would not hear from her lawyer what was not correct or missing from the insurance company´s doctor. We were informed that we could appeal within his decision within 90 days otherwise we would receive a settlement of $8500 minus lawyers fees ( on a policy that already had over $7000 in back pay and potential of additional $31000).
Part of the deception of the insurance company is their settlement release form which I never signed and I never agreed to this settlement. In it there are non disclosure paragraphs throughout with threaten a person and its family with financial ruin should they break this settlement. Also threats if the news media was ever told of what happened. They also state that the claimant agrees she was not disabled ( she would NEVER sign anything link this) and they are not held accountable for anything even breaking a law or other reasons why they were wrong in termination of her.
I have documentation of this and everything else written in this letter and if you are serious about helping me I will gladly send copies to you
Please help the poor disabled people who depended on these insurance policies to be able to have a quality of life, by changing the laws so the insurance companies will have to payout the full policy.
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