From THE CFIDS CHRONICLE  FALL 1996
   The CFIDS Association of America, Inc.
   PO Box 220398
   Charlotte, NC 28222-0398
   1-800-442-3437
   
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                   Suggestions for Filing CFIDS LTD Claims
   
                               By Annie Bloom
   
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   Your application and all supporting evidence will be scrutinized by
   insurance claims personnel trained to find weaknesses that can be used to
   delay, deny or limit your benefits.  Careful preparation in the early stages
   of your LTD claim is essential and can help you avoid common mistakes.  Take
   your time and go through each step of the process slowly If you are very
   ill, ask a trusted friend to help you.
   
   1.      Obtain a copy of your complete LTD policy from your employer or
   directly from the insurance company; read it thoroughly before applying for
   benefits.  Note: pamphlets that describe your benefits or certificates of
   insurance given to employees are not policies; if there is any difference in
   language, the language in the policy prevails.
   
   2.      Determine whether your LTD insurance is an individual policy or an
   employee benefit.  Most group LTD policies are employee benefits, which are
   covered under a federal law called the Employee Retirement Income Security
   Act (ERISA).  Individual policies are governed by state laws which are
   usually more favorable to the claimant and allow suits to be brought against
   insurers for bad faith.
   
   3.      Understand all terms used in the policy, including disability,
   covered employment, exclusion or elimination period, pre-existing condition,
   special limitations for certain conditions and proof of claim.  Insurers
   sometimes distinguish between being disabled from your job (the position you
   hold with your employer); being disabled from your occupation (similar work
   done for another employer); and being disabled from any occupation for which
   you are reasonably qualified.
   
   4.      Note all time limits that apply to eligibility, elimination period,
   providing proof of claim, appealing denials and filing a lawsuit; observe
   them carefully.  Note how many hours per week you must be working to be
   covered for benefits, and whether you must be totally or partially disabled
   to be eligible.  If you reduce your work hours due to illness, be sure to
   document the date you left full-time employment and obtain a letter from
   your doctor clarifying that the reduction in your hours was for medical
   reasons.
   
   5.      Work closely with your doctor(s) to provide the strongest possible
   evidence in support of your claim.  Medical reports submitted with
   applications or appeals should include the following:
   
   7       a strong statement confirming your CFIDS diagnosis and your
   inability to work;
   7       detailed application of current CDC criteria and your medical
   history to support your diagnosis;
   7       documentation of all physical signs, abnormal lab tests and other
   objective evidence of illness;
   7       a statement that you are totally disabled and unable to do any kind
   of work, if applicable;
   7       a detailed explanation of how your specific symptoms limit or
   preclude any work activity;
   7       results of functional capacity or exercise tolerance tests, if
   possible, to support your inability to work;
   7       Objective evidence that all other possible causes for your symptoms
   have been carefully excluded (lab tests, reports from specialists, etc.).
   
   Throughout your claim, be prepared to provide ongoing documentation of all
   signs and symptoms that support your diagnosis and your inability to work.
   Your doctor may be asked to submit additional information, including office
   notes and written reports.
   
   6.      Be aware of two-year limitations.  Many policies contain two-year
   limitations for mental illness and nervous conditions.  Your insurer may
   look for reasons to classify you as mentally ill in order to limit your
   benefits.  If symptoms of depression or anxiety must be documented, be sure
   your doctor clarifies that they are secondary to the illness and did not
   exist before.  New and renewal policies may also include two-year
   limitations for "chronic fatigue conditions," "allergies to chemicals or the
   environment" and "self-reported" symptoms such as "chronic fatigue" and
   "muscle pain" which cannot be confirmed by objective laboratory testing.
   These new limitations do not apply to existing claims filed under policies
   written before the new language was adopted.
   
   7.      Maintain a chronological file of all documentation and
   correspondence related to your claim, including your initial application,
   information from your employer and physician's statement; all medical
   information submitted; all letters from you, your insurer and your attorney;
   and any supplemental forms you complete.  Review this file frequently to
   catch and clarify any details you may have missed, and note patterns of
   delays or denials.  You are also legally entitled to copies of everything
   your insurer has in your file, including internal memos, reports from
   independent medical examinations required by the insurer and any
   surveillance videos your insurer has ordered from private investigators.
   Consult an attorney or your state insurance commissioner if you are denied
   access to this information.
   
   8.      Your LTD benefit is the maximum amount you can receive from all
   employment-related sources under most group policies.  For example, any
   additional income you receive from part-time work, short-term disability,
   state disability, Social Security and some retirement plans can and will be
   deducted from your benefit amount.  If you receive back payments from SSDI
   while receiving LTD payments, you may owe all or part of this to your LTD
   carrier.  If other family members receive Social Security benefits due to
   your illness, expect your LTD insurer to deduct that income from your
   benefits, too.  Determine what percentage of the premium (if any) is paid by
   your employer; the same percentage of any benefits paid to you will be
   considered taxable income by the IRS.
   
   9.      You have the right to seek representation by an attorney.  If your
   LTD insurance is an employee benefit, look for an attorney experienced in
   ERISA law and handling CFIDS claims.  Discuss fee arrangements in advance.
   Options may include paying hourly for assistance in writing letters, appeals
   and filing a civil suit; paying a retainer for a thorough review of your
   medical evidence and claims file, with additional time billed by the hour;
   or negotiating a contingency arrangement in which your attorney will receive
   a percentage of your benefits.  The latter is commonly used when a case goes
   to trial.  Weigh the value of your benefits against your estimated legal
   expenses.  If you can't afford an attorney, look for a paraprofessional
   trained to advise disabled claimants.
   
   10.     Obtain legal advice early in the claims process.  Strengths and
   weaknesses in the initial application can have a major impact on the outcome
   of your claim.  If your insurer offers you a cash settlement in exchange for
   relinquishing your rights to future benefits, insist on being allowed time
   to review the offer in written form, weigh its merits and obtain qualified
   legal advice before signing away your rights.  Many offers are ridiculously
   low, never put in writing or withdrawn after a short time.
   
   Members of your local support group, bar association or disability rights
   groups may be able to recommend attorneys who have successfully handled
   ERISA claims for CFIDS patients.
   
   11.     Be sure to appeal denials within the stated time limit.  Whenever
   possible, have an attorney draft your appeal, highlighting the strengths of
   your medical evidence, weaknesses in the insurer's denial and citing
   relevant sections of ERISA and other applicable laws.  Remember that
   insurers do not care about the pain and hardships claimants must endure;
   they are only interested in the relevant facts of your case.
   
   12.     Strengthen your case by providing additional medical evidence when
   you appeal a denial; relevant articles published in peer-reviewed medical
   journals can be used to support your evidence.  Also consider obtaining
   functional capacity evaluations or vocational appraisals by persons trained
   to assess your ability to work full or part time if you have not done so
   already.  Any of these strategies will also strengthen initial applications
   for benefits.
   
   13.     Be prepared for independent medical examinations (IMES) by doctors
   paid by your insurer to evaluate your disability.  Some insurers go out of
   their way to schedule IMEs with cynics who do not recognize CFIDS as a valid
   diagnosis.  Try to find out about your examiner's experience and attitudes
   toward CFIDS and how much of their work is for insurance companies.  Ask if
   you can bring an observer or tape recorder to the examination.  Avoid
   appearing antagonistic, but be prepared to document any irregularities in
   the examination or indications of obvious bias by the examiner.
   
   14.     Expect difficulties after the first two years of your claim.  Many
   insurers try to limit their liability to a maximum of two years of benefits.
   After two years, depending on the,contract your insurer has with your
   employer, you may need to prove disability from any occupation to be
   eligible for further benefits.  Also be prepared for increased frequency of
   IMES, home visits, surveillance, harassment and attempts at intimidation.
   
   --
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