Quote:
Originally Posted by zookester
Hey Nanc,
Do you know what diagnosis codes your doctor is using? Did you keep a copy of all of your work release letters from your treating physicians from the time you initially went out on STD? When you left your job was it because a new injury caused spread/increase in pain or was it possibly work related repetition that made things suddenly unbearable? ... bare with me on my gazillion questions... just reaching here. Did they give you any reason for the approval and then denial after the initial week? Are you saying that your STD/LTD claims manager is your employer or do you have an actual claims manager outside of your employer?
When I initially applied for STD/LTD I was assigned a claims manager and it was that person alone with whom I had direct contact with. I made sure to gather copies of all of my records and constantly flooded the claims manager with emails and faxes with chart notes, work release letters & additional diagnosis. They also requested formal records about every 12 weeks and before extending benefits again (usually in 3-4 month intervals). When we were approaching the 2 year mark the LTD rules have different guidelines in that you must be unable to do "any" job, not just the job you were currently doing. I believe that is fairly standard language in most LTD contracts but, you would have to read your through to be certain. I was then required to fill out many more forms asking about my limitations etc., as well as provide information on current medications, physicians list etc., It was right about that time that I had undergone a complex hip surgery and this resulted in nerve damage that caused the CRPS II and I immediately phoned my rep and then followed up with a copy of Dr. Hooshmands article on The spread of CRPS. One week later - I received a letter extending my LTD until the age of 65 instead of the normal 3-4 month intervals, I was shocked and relieved. I'm not sharing this with you to make you feel bad because of the way my case was handled but, wondering if your claims manager doesn't understand CRPS? I wonder if your diagnosis codes are accurate? Did you get a return to work request from your employer for your physician to fill out? If so did they properly list your limitations or excuse you from duties?
In your shoes, I would certainly appeal.. something is just not right. I know it is exhausting and stressful but, it seems from what you have shared that something is missing. I would fight!
Hang in there,
Tessa
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Hey Tessa,
Sorry but this is a very long reply, but I wanted to address all your questions.
I do not know of any diagnosis codes my dr used. I do not have any work release letters as I was never released to go back to work. My RSD spread and pain got to where I just couldn’t keep up in my job. In other words, I could not bear the pain any longer. The SCS’s were implanted in June 2011 (revision in Nov 2011) and they enabled me to continue working for another year and a half. The RSD kept progressing and the SCS’s effectiveness was wearing off. I was not sleeping because of the pain, doing my job was taking longer because of my hand and arm pain, I was having these additional pain attacks in my head, side and foot that effected everything (including driving). With RSD in my leg and feet, it was hard to sit in one position very long. I had difficulty walking to the copier and workroom at work. I was finding mistakes that I was making in my job, which was not good when you handle all the finances and hr for the organization. The more I used my hands, the more they hurt! I could not take pain meds when I was working. The insurance carrier did not give any reason for covering one week of STD. They sent a check for that period and that is all. The denial letters just stated that I was not approved for benefits beyond that period -?? My claim’s manager was not my employer; my boss was the employer contact on my claim. I was not exactly assigned a “claims manager”. Our claims were processed as follows: the employee completed form, employer completed form and the physician’s statement (form) all sent in with a copy of my outdated job description. On the drs statement, he put “unknown” as the date expected to return to work. I think the thing that did me most harm is that my dr had me do the functional capacity evaluation (FCE) which stated I could do sedentary work. My job was pretty much classified as sedentary. This FCE did not test real working environment, it tested how much weight I could push, pull and lift. Where is that relevant in my type of job?? The girl who did the FCE made mistakes on it. I tried to contact her and she would not return any of my calls. My dr said he could not say I was totally disabled because the FCE said I could do sedentary level. He said he couldn’t make that determination, even when I showed him the letter my PCP wrote stating I was totally disabled and she advised me to apply for disability (she did for the last two years). HE screwed me over on this whole thing, which is why I am looking for a new PM dr. I wanted to have a new FCE done and checked around, all of them are done the same way…they do not test on the computer, etc.
I was initially contacted by a claims analyst. She never returned any of my calls. They received my initial claim 12/6/12 and my last day was 12/28/12. I had to train a temp to do my job since no one else there knew how to do anything I did. They denied my claim 1/18/13. I had to get a claims supervisor involved because the mishandling of my claim. They only requested records from my PM dr for two months…that is two visits! He changed practices 10/1/12, anything prior was at the old practice and I offered over and over to get these records and send them. They didn’t want them. They denied the initial claim based on the FCE and two months of records. Wasn’t surprised there! So in the appeal, I sent all medical records – from all visits to this PM and others I have seen, PCP, foot dr, neurologists, allergist, dermatologist, everything!! ALL of my medical records note RSD/CRPS of upper & lower extremities, trunk and head. Also sent the letter from my PCP and letter my PM wrote. PM would not say I was totally disabled, but he did say that the FCE did not test real working environment, that my RSD is progressing, that I am in the later stages of RSD and we have eliminated all treatment options, etc., it was a decent letter. When I received my SSD award letter, I forwarded it to them. To get SSD, you have to be unable to do any job. In my STD/LTD plan documents, I have to be unable to do any of the duties in my current job.
There was no return to work request from my employer. When I left 12/28/12, they said they would hold my position a max of 90 days. My RSD was progressing and I was getting worse even after the last day worked. I was denied STD and not getting paid. I could not get my 401k until my employment was terminated and needed it in order to keep our house. They would not release me so I resigned effective 3/4/13 due to my medical condition (I did receive confirmation that this would not interfere with my disability claim appeal as they go by disability date).
I do not know what more could be supplied to them in the next appeal to make them overturn their decision ??
Thanks for your reply and help! What a stressful mess this is!
Nanc
