Looking for a professional medical opnion RE: MS and Spinal Taps
- Thread starter Ratina
- Start date
Ratina
Bronze Knight of the Realm
- 243
- 79
There might actually be an end to the LTD in sight. I don't think they can say no now. You have no idea the amount of pressure this will relieve.
Neuro filled out this for the 'Independent' reviewer.
My GP wrote this letter.
fingers, toes, paws, and fins crossed
Neuro filled out this for the 'Independent' reviewer.
My GP wrote this letter.
fingers, toes, paws, and fins crossed
Ratina
Bronze Knight of the Realm
- 243
- 79
Should be 60% of my Sr SysAdmin salary, but I paid taxes on the contributions so I get to collect tax free I think. Take home would be about the same as when I was working full time.
They will get me into SSD because they will get to of set what they need to pay me by whatever they can get the government to pay. Advantage here is I should be able to drop most of my student loan debt, and access to better health insurance programs.
The policy will pay out till im 65.
So you can now 'rest easy' and start treatment it sounds like. Crappy you have MS but at least you don't have to worry as much about whether or not you will eat while you deal with it!
Ratina
Bronze Knight of the Realm
- 243
- 79
Its better than that. My career was on fire when and even after I was diagnosed. My shit heel boss drove me out of the company so the pending suit might add some fuck you money on top, but I have way more income than obligations so I should be able to pull off going to MTG GPs or food tourism trips, I actually don't know what yet.
The MS itself is problems with the right arm and left leg. and a general slowness and clumsiness. Depending on how I feel, the temperature, etc these things have some varying degree of effect on those three aspects. I have to accept that sometimes my body will say I can not meet an obligation, but for the most part if I plan ahead and pace myself i can manage it. The real goal is to not have another attack where the nerves actually get damaged. My left leg damage was from an attack that started while I was on a health/exercise kick. I was on a treadmill when my left foot started slapping down flat on the belt every step instead of the balls of the feet. Followd by half my body going numb, then problems with talking, that led me to the doctors to find out I had MS. Second major attack fucked up my right arm and brought the fatigue to an intolerable level. This attack was caused by stress, and probably because I heavily drank the first few years after diagnosis. I plan to keep the stress down and just manage the symptoms I have.
Ratina
Bronze Knight of the Realm
- 243
- 79
Seriously, fuck insurance companies.
I wish to appeal the denial of benefits sent to me January 07 2016. I refer to the claim filed with Prudential to determine my eligibility for the continuation of my group life insurance during total disability under Group Policy xxxx
You claim I do not meet the requirements to receive benefits because I am not "totally disabled" and state "Although you are unable to perform your previous work, your conditions would not preclude all work activity. Based on your work and educational history, you have transferable skills to perform alternative sedentary occupations. "
I thought the wording was funny, and I did not actually make the claim in the first place. Last I knew I passed on converting my policy when I was terminated from my employer. Best guess is the approval of the actual LTD claim auto applied for this.
I checked my LTD policy and sure enough; first two years pay if I can no longer do the job I had, but after that the policy only pays if you are "totally disabled".
I do not want to appeal the claim as much as I want to resolve the status of not being "totally disabled" before the second year of my LTD is up.
This is an attempt to engage in an interactive process with Prudential. I request, as a Prudential customer, my case be handled by one person to expedite this process. Having to pour energy into appeals is negatively effecting my health. It hurts to fight, what can we do so I don't have to fight all the time?
I have Multiple Sclerosis; multiple doctors have advised me that I should seek disability because it's impossible I could hold gainful employment. I've been told "yeah you need to retire" and "You have definitive disabling MS there's not even a question."
LTD insurance was explained to me that if I lose the ability to generate income, the insurance company will replace a portion of my income so i can avoid bankruptcy.
My first claims manager said she felt I was entitled to the claim we just needed the medical to come back ok.
The medically necessary report was delayed as Prudential requested more information from my doctor and informed me they were exercising the time extension option on my claim.
My doctor informed me that Prudential was asking about the range of motion of my right thumb.
I wrote a letter to my claims examiner expressing my concern that the wrong aspects of my illness were being evaluated for the claim. I tried to explain the MS related fatigue was the reason I couldn't work, and what could I do to clear up the confusion.
The claim came back denied because it was not medically necessary. When I talked to my claims manager I asked about the letter and how I asked what can I do to help. She responded 'they' are never going to tell you what to fix.
I went over the denial and saw that a doctor's report was filled out poorly and this led to the denial. I corrected the doctor's information and sent in my appeal with an explanation of how the doctor situation got messed up. And some additional supporting evidence.
The denial stated "Although you have reported cognitive symptoms, there is no documentation of abnormal mental status testing or neuropsychological testing that supports cognitive impairment.
My neurologist had me take a neuropsychological test as additional evidence for the appeal.
My general practitioner, learning of my difficulties getting LTD approved, added his professional medical opinion that I could not pursue gainful employment as additional evidence for the appeal.
I was informed Prudential was going to exercise its time extension option on the appeal.
The appeal was granted and Prudential paid on the policy. A few days later I got the claim denial referenced at the start of this letter.
I assume Prudential will be trying to drop me after the two years, and I will appeal, and Prudential will exercise its time extension option on that appeal.
I do not see any reasonable way I could hold gainful employment. Every doctor I've dealt with says there is no reasonable way I could hold gainful employment. I am confident any face to face meeting with any doctors, lawyers or judges they would agree there is no reasonable way I could hold gainful employment. I intend to appeal anything short of a "totally disabled" decision until the case gets in front of a judge.
It is to that judge I ask; at what point do I get to say Prudential is acting in bad faith? I am willing to see any doctor that they choose, I'm willing to try any return to work program that will not risk my health, I will take any test they want. Every time I ask Prudential for help I am told I just need to fit the description of disabled as defined under the policy, and a copy of the policy definitions.
So let's look at the actual definitions.
The LTD policy states: "In order to be eligible for LTD benefits, you must meet all of the terms of the LTD policy including the definition of disability as defined in the attached Long Term Disability Policy Provisions."
The Long Term Disability Policy Provisions states: "You are disabled when Prudential determines that: you are unable to perform the material and substantial duties of your regular occupation due to your sickness or injury; and you are under the regular care of a doctor; and you have a 20% or more loss in your monthly earnings due to that sickness or injury.
After 24 months of payments, you are disabled when Prudential determines that due to the same sickness or injury: you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience; and you are under the regular care of a doctor."
On January 4th Prudential approved that claim "we have determined that you are currently disabled from your regular occupation". Prudential previously stated my regular occupation as "consistent with the occupation Senior System Administrator, which is a sedentary level occupation. This occupation requires frequently sitting, occasionally reaching, walking, fingering, and rare to occasional standing."
To reiterate, Prudential's reason of why I do not qualify as "totally disabled" in the claim I am currently appealing states "Although you are unable to perform your previous work, your conditions would not preclude all work activity. Based on your work and educational history, you have transferable skills to perform alternative sedentary occupations. "
My work and education history shows I dropped out of high school and have no college degree. I do, however have a ton of IT certs and several years of high end IT work experience. My only transferable skills are IT related, so is Prudential actually telling me I could not work my sedentary IT job, but I am not totally disabled because I could work a sedentary IT job?
It gets worse; Prudential said I couldn't prove cognitive impairment because I did not have a neuropsychological test done. So I had the test done and Prudential stated I couldn't prove cognitive impairment because ". testing was done by the provider . There is no evidence in file that a comprehensive neuropsychological examination has been done by a neuropsychologist to support his findings."
If Prudential requires extra things to consider this test valid, why did it not inform me of the policy so I could get the test done the 'right' way? What's the problem with having the test done "by my provider"? Is Prudential implying a board certified neurologist who specializes in MS is not qualified to administer a test that's used to measure MS fatigue? Or is it that he gets paid to provide a service? Is Prudential implying that because he is being paid he is not objective? How can I get the test done without paying someone to administer it? Will Prudential pay to have an independent doctor administer the test for me?
The denial goes on to say "The evidence in file supports that you have the following restrictions and/or limitations due to multiple sclerosis: Stand and walk up to 4 hours." Where did this figure come from? My neurologist plainly stated to the 'independent' doctor Prudential hired that "The fatigue makes it next to impossible for him to function at any level of a income earning job due to need for prolonged breaks (1-2 hr) after as short a time as 1-2 hr of work. The cognitive difficulties makes it extremely difficult for him to work at his prior job due to need for continued retraining and slowness of function and higher rate of errors.".
Can the 'independent' doctor just change my doctor's recommendations without even talking to me let alone any type of examination? Can I imply that because he is being paid he is not objective? I flat out can't do 'stand and walk for 4 hours' on a good day, bad days I can't stand and walk to the bathroom for 4 minutes.
I am still working under the assumption that the Prudential Insurance Company intends to fulfill its contractual obligations and pay on legitimate claims under its LTD policy's. I mentioned to one of the claim managers that there was a lot of hoops to jump through to keep fraud down. She said that actually fraud is a rare thing it wasn't a factor. Wouldn't that mean all these hoops are there just to try to not pay on the claim?
Also, Prudential hired a 3rd party to apply for SSD benefits because Prudential is allowed to offset anything SSD would give me and have to pay out that much less. If Prudential believes I am not "totally disabled" and applied for SSD benefits so it could recoup money how is that not SS fraud? I will be going to the SS office myself to apply for SSD. I am starting to not trust that you have me, your client's, best interest in mind. I will find out from them directly.
Please respond and assist me in what I need to change to get the right words in the right place.
I have MS, MS can qualify as a disability if it is severe enough, my MS is severe. I am 100% open to elaborating on any of these items, testing, more doc visits.
I feel as if I had both legs removed I would not have to say I have problems walking, running, jumping, skipping, etc. It should be assumed with the general idea of I had both legs removed. Prudential claims a neurologist looked at my claim but makes no mention of the fatigue. MS fatigue effects up to 80% of MS patients, and is the number one reason those patients become disabled. It's such a prevalent and medically accepted phenomena the SSD rip sheets have an entry specifically for MS fatigue. Was the neurologist used just not familiar with MS and its mechanisms?
If Prudential's response to this appeal is another copy and paste of the policy's wording without addressing any of my questions I will consider opening a bad faith suit. I will apply for an injunction so Prudential can't stop payments after the 24 month period if this issue is not resolved. My intention for having LTD insurance was so that if something bad happened I would not become bankrupt over it. I have asked for help numerous times how to use the service they are providing with no satisfactory answers. I will also start tracking time and money invested into getting what was promised by Prudential via its LTD policy with the intention of seeking damages.
I wish to reiterate, the nature of MS and its accompanying fatigue means the effort I had to put into this appeal was exhausting. I have been working on this document for almost a month. Few hours here, few hours there, but always as a tradeoff for something else I could not do. I had to make decisions on whether I should cook dinner or work on this appeal.
If I only get 4 good hours in a day I want to spend those 4 hours helping my mother, or spending time with my rescue dog who needs far too much coddling, not playing cat and mouse over definitions to try to get the LTD moved forward.
It even sucks to type, my right hand has poor motor control combined with brain fog dropping words or just blatant mistyping, means I spend as much time editing each line as it took to write it. And I slur from the MS too much to use voice recognition software.
Tell me you think I'm faking or exaggerating. Tell me you think my doctors are lying. Tell me MS fatigue is not a real thing. Tell me to get this or that test done. Please tell me how we can resolve this quickly and finally.
The stress of not knowing if I will be able to keep my house or if I will lose my income makes the MS worse. I kept quality of life diaries when this all started, would it help if I explicitly said how often I need to rest versus productive moments? Will it help to describe the frequency of bathroom accidents? How many times I've had to rest in the car from grocery shopping before I could drive home safely. Should I get affidavits from people who have seen me collapse at a wedding or drop items at the store?
I eagerly seek your response so we can resolve this.
I wish to appeal the denial of benefits sent to me January 07 2016. I refer to the claim filed with Prudential to determine my eligibility for the continuation of my group life insurance during total disability under Group Policy xxxx
You claim I do not meet the requirements to receive benefits because I am not "totally disabled" and state "Although you are unable to perform your previous work, your conditions would not preclude all work activity. Based on your work and educational history, you have transferable skills to perform alternative sedentary occupations. "
I thought the wording was funny, and I did not actually make the claim in the first place. Last I knew I passed on converting my policy when I was terminated from my employer. Best guess is the approval of the actual LTD claim auto applied for this.
I checked my LTD policy and sure enough; first two years pay if I can no longer do the job I had, but after that the policy only pays if you are "totally disabled".
I do not want to appeal the claim as much as I want to resolve the status of not being "totally disabled" before the second year of my LTD is up.
This is an attempt to engage in an interactive process with Prudential. I request, as a Prudential customer, my case be handled by one person to expedite this process. Having to pour energy into appeals is negatively effecting my health. It hurts to fight, what can we do so I don't have to fight all the time?
I have Multiple Sclerosis; multiple doctors have advised me that I should seek disability because it's impossible I could hold gainful employment. I've been told "yeah you need to retire" and "You have definitive disabling MS there's not even a question."
LTD insurance was explained to me that if I lose the ability to generate income, the insurance company will replace a portion of my income so i can avoid bankruptcy.
My first claims manager said she felt I was entitled to the claim we just needed the medical to come back ok.
The medically necessary report was delayed as Prudential requested more information from my doctor and informed me they were exercising the time extension option on my claim.
My doctor informed me that Prudential was asking about the range of motion of my right thumb.
I wrote a letter to my claims examiner expressing my concern that the wrong aspects of my illness were being evaluated for the claim. I tried to explain the MS related fatigue was the reason I couldn't work, and what could I do to clear up the confusion.
The claim came back denied because it was not medically necessary. When I talked to my claims manager I asked about the letter and how I asked what can I do to help. She responded 'they' are never going to tell you what to fix.
I went over the denial and saw that a doctor's report was filled out poorly and this led to the denial. I corrected the doctor's information and sent in my appeal with an explanation of how the doctor situation got messed up. And some additional supporting evidence.
The denial stated "Although you have reported cognitive symptoms, there is no documentation of abnormal mental status testing or neuropsychological testing that supports cognitive impairment.
My neurologist had me take a neuropsychological test as additional evidence for the appeal.
My general practitioner, learning of my difficulties getting LTD approved, added his professional medical opinion that I could not pursue gainful employment as additional evidence for the appeal.
I was informed Prudential was going to exercise its time extension option on the appeal.
The appeal was granted and Prudential paid on the policy. A few days later I got the claim denial referenced at the start of this letter.
I assume Prudential will be trying to drop me after the two years, and I will appeal, and Prudential will exercise its time extension option on that appeal.
I do not see any reasonable way I could hold gainful employment. Every doctor I've dealt with says there is no reasonable way I could hold gainful employment. I am confident any face to face meeting with any doctors, lawyers or judges they would agree there is no reasonable way I could hold gainful employment. I intend to appeal anything short of a "totally disabled" decision until the case gets in front of a judge.
It is to that judge I ask; at what point do I get to say Prudential is acting in bad faith? I am willing to see any doctor that they choose, I'm willing to try any return to work program that will not risk my health, I will take any test they want. Every time I ask Prudential for help I am told I just need to fit the description of disabled as defined under the policy, and a copy of the policy definitions.
So let's look at the actual definitions.
The LTD policy states: "In order to be eligible for LTD benefits, you must meet all of the terms of the LTD policy including the definition of disability as defined in the attached Long Term Disability Policy Provisions."
The Long Term Disability Policy Provisions states: "You are disabled when Prudential determines that: you are unable to perform the material and substantial duties of your regular occupation due to your sickness or injury; and you are under the regular care of a doctor; and you have a 20% or more loss in your monthly earnings due to that sickness or injury.
After 24 months of payments, you are disabled when Prudential determines that due to the same sickness or injury: you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience; and you are under the regular care of a doctor."
On January 4th Prudential approved that claim "we have determined that you are currently disabled from your regular occupation". Prudential previously stated my regular occupation as "consistent with the occupation Senior System Administrator, which is a sedentary level occupation. This occupation requires frequently sitting, occasionally reaching, walking, fingering, and rare to occasional standing."
To reiterate, Prudential's reason of why I do not qualify as "totally disabled" in the claim I am currently appealing states "Although you are unable to perform your previous work, your conditions would not preclude all work activity. Based on your work and educational history, you have transferable skills to perform alternative sedentary occupations. "
My work and education history shows I dropped out of high school and have no college degree. I do, however have a ton of IT certs and several years of high end IT work experience. My only transferable skills are IT related, so is Prudential actually telling me I could not work my sedentary IT job, but I am not totally disabled because I could work a sedentary IT job?
It gets worse; Prudential said I couldn't prove cognitive impairment because I did not have a neuropsychological test done. So I had the test done and Prudential stated I couldn't prove cognitive impairment because ". testing was done by the provider . There is no evidence in file that a comprehensive neuropsychological examination has been done by a neuropsychologist to support his findings."
If Prudential requires extra things to consider this test valid, why did it not inform me of the policy so I could get the test done the 'right' way? What's the problem with having the test done "by my provider"? Is Prudential implying a board certified neurologist who specializes in MS is not qualified to administer a test that's used to measure MS fatigue? Or is it that he gets paid to provide a service? Is Prudential implying that because he is being paid he is not objective? How can I get the test done without paying someone to administer it? Will Prudential pay to have an independent doctor administer the test for me?
The denial goes on to say "The evidence in file supports that you have the following restrictions and/or limitations due to multiple sclerosis: Stand and walk up to 4 hours." Where did this figure come from? My neurologist plainly stated to the 'independent' doctor Prudential hired that "The fatigue makes it next to impossible for him to function at any level of a income earning job due to need for prolonged breaks (1-2 hr) after as short a time as 1-2 hr of work. The cognitive difficulties makes it extremely difficult for him to work at his prior job due to need for continued retraining and slowness of function and higher rate of errors.".
Can the 'independent' doctor just change my doctor's recommendations without even talking to me let alone any type of examination? Can I imply that because he is being paid he is not objective? I flat out can't do 'stand and walk for 4 hours' on a good day, bad days I can't stand and walk to the bathroom for 4 minutes.
I am still working under the assumption that the Prudential Insurance Company intends to fulfill its contractual obligations and pay on legitimate claims under its LTD policy's. I mentioned to one of the claim managers that there was a lot of hoops to jump through to keep fraud down. She said that actually fraud is a rare thing it wasn't a factor. Wouldn't that mean all these hoops are there just to try to not pay on the claim?
Also, Prudential hired a 3rd party to apply for SSD benefits because Prudential is allowed to offset anything SSD would give me and have to pay out that much less. If Prudential believes I am not "totally disabled" and applied for SSD benefits so it could recoup money how is that not SS fraud? I will be going to the SS office myself to apply for SSD. I am starting to not trust that you have me, your client's, best interest in mind. I will find out from them directly.
Please respond and assist me in what I need to change to get the right words in the right place.
I have MS, MS can qualify as a disability if it is severe enough, my MS is severe. I am 100% open to elaborating on any of these items, testing, more doc visits.
I feel as if I had both legs removed I would not have to say I have problems walking, running, jumping, skipping, etc. It should be assumed with the general idea of I had both legs removed. Prudential claims a neurologist looked at my claim but makes no mention of the fatigue. MS fatigue effects up to 80% of MS patients, and is the number one reason those patients become disabled. It's such a prevalent and medically accepted phenomena the SSD rip sheets have an entry specifically for MS fatigue. Was the neurologist used just not familiar with MS and its mechanisms?
If Prudential's response to this appeal is another copy and paste of the policy's wording without addressing any of my questions I will consider opening a bad faith suit. I will apply for an injunction so Prudential can't stop payments after the 24 month period if this issue is not resolved. My intention for having LTD insurance was so that if something bad happened I would not become bankrupt over it. I have asked for help numerous times how to use the service they are providing with no satisfactory answers. I will also start tracking time and money invested into getting what was promised by Prudential via its LTD policy with the intention of seeking damages.
I wish to reiterate, the nature of MS and its accompanying fatigue means the effort I had to put into this appeal was exhausting. I have been working on this document for almost a month. Few hours here, few hours there, but always as a tradeoff for something else I could not do. I had to make decisions on whether I should cook dinner or work on this appeal.
If I only get 4 good hours in a day I want to spend those 4 hours helping my mother, or spending time with my rescue dog who needs far too much coddling, not playing cat and mouse over definitions to try to get the LTD moved forward.
It even sucks to type, my right hand has poor motor control combined with brain fog dropping words or just blatant mistyping, means I spend as much time editing each line as it took to write it. And I slur from the MS too much to use voice recognition software.
Tell me you think I'm faking or exaggerating. Tell me you think my doctors are lying. Tell me MS fatigue is not a real thing. Tell me to get this or that test done. Please tell me how we can resolve this quickly and finally.
The stress of not knowing if I will be able to keep my house or if I will lose my income makes the MS worse. I kept quality of life diaries when this all started, would it help if I explicitly said how often I need to rest versus productive moments? Will it help to describe the frequency of bathroom accidents? How many times I've had to rest in the car from grocery shopping before I could drive home safely. Should I get affidavits from people who have seen me collapse at a wedding or drop items at the store?
I eagerly seek your response so we can resolve this.
Oldbased
> Than U
- 27,768
- 65,334
And even then expect a long frustrating fight. Lady I live with is 53, had first possible diagnosis in 2005, confirmed with spinal tap in 2013 and 3x a month visits with 3 doctors now for over a year, all while degrading farther and trying different medicines including one that cost thousands a month and still hasn't been able to get disability. She got a lawyer 6 months ago and we are still waiting on a hearing. I had to go pick her up twice in the last month at stores then deal with getting her car home where she felt like she could go grab a few things from a store, got inside it and didn't have the energy/eyesight/balance to get back out. She has statements from dozens of people in addition to near a dozen different doctors/therapists and such saying she is unable to function and a stack of records a foot high and it doesn't feel any closer to being given than day 1.
None of her treatments/drugs have seemed to work but at least the copaxone seems it may be keeping it from getting worse. Some of those medications damn near killed her with side effects.
On the other hand would like to give Meijer props, they know of her condition and my heart failure( we get soooo many prescriptions a month filled there and most of our shopping ) that they usually unload her cart for her to checkout and take it to the car and have recently started to try to do the same for me. Considering she looks 40 and healthy, is 50s and has the actual health/mobility of someone probably in 90s that means a whole lot to us.
None of her treatments/drugs have seemed to work but at least the copaxone seems it may be keeping it from getting worse. Some of those medications damn near killed her with side effects.
On the other hand would like to give Meijer props, they know of her condition and my heart failure( we get soooo many prescriptions a month filled there and most of our shopping ) that they usually unload her cart for her to checkout and take it to the car and have recently started to try to do the same for me. Considering she looks 40 and healthy, is 50s and has the actual health/mobility of someone probably in 90s that means a whole lot to us.
Ratina
Bronze Knight of the Realm
- 243
- 79
I am trying to not give away 10% of something I feel I am entitled to via the policy I paid for.
The way it works is on the 3rd appeal of something, all evidence is locked before it goes to a judge. If I get near that threshold I will get a lawyer, 90% is better then 0%