Things to watch and do in filing Long Term
From THE CFIDS CHRONICLE FALL 1996
The CFIDS Association of America, Inc.
PO Box 220398
Charlotte, NC 28222-0398
Suggestions for Filing CFIDS LTD Claims
By Annie Bloom
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
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
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.
alt.health.cfs - an unmoderated medical discussion of CFIDS & FM
Available through www.dejanews.com
See you there!!!!!!
Top of Page
Uncivilization and its Discontents
Email Judy Morris
at: judydoc AT the-spa DOT com
at: bhammel AT graham DOT main DOT nc DOT us
The URL for this document is:
Created: October 16, 1998
Last Updated: May 28, 2000