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How can the disability insurance company deny my claim if my doctor has not released me to return to work?



Disability attorney Stephen Jessup discusses a disability insurance companies right to deny a claim even though the claimant has not been released to return to work by their doctor.

We get a lot of calls from people who say their claims have been denied even though their doctors haven’t told them they can go back to work; they haven’t been “released for work.” However, the insurance company, upon receipt of the claim, is going to start doing their own medical investigation. They’re going to send it to their doctors for review; they may send it out to an independent doctor to do a peer review. If one of those doctors come back and say, “Well, I don’t find any restrictions and limitations or medical reasons as to why this person shouldn’t be working,” the insurance company can rely upon those doctors to deny your claim, regardless of what your actual treating physicians are stating.

There are 59 opinions so far. Add your comment below.

Kelly:

I have a new claims manager, within the last nine months. He asked for a APS from my Cardiac Surgeon, which we supplied, in November, 2015. I have been on Long Term Disability for 8 years, for 3 Heart Surgeries and some other health issues. He called me two days ago, to say, this same Dr., send another APS in for me, releasing me back to work? I said I don’t know anything about this, as far as I know my Dr., has me off work, I have to check with him. I just got out of the hospital 7 weeks ago, for another very serious problem, which I reported to you. He said he had no record of it? I called my Doctors office later that day and they said that this was true. They had received another Attending Physians Statement, but hadn’t sent it in yet. Will the insurance company out and out lie to you and is that even legal? He was also really rude to me. He called on my Birthday and I think he did it just to upset me. I asked if he knew it was my Birthday and he simply said, “Should I call back tomorrow?” Nothing else. I said, no, go on and he did. It was really weird. I had to ask him 3 times, if he had my file in front of him, because the last 3 things I had called into the Company, he didn’t know. Like the fact that I had just gotten out of the hospital, 7 weeks ago and had to have a blood transfusion, 6 bags of blood. I almost died, I was very sick and still am. They are running tests. I am always really good about updating my medical records, but he acted like he didn’t have any of that information. I have never been treated like this, by them before. As I said, he is new to my claim and I am curious to hear your response. I have Aetna Long Term Disability. I purchased it when I was working, for an employer. Thank you, Kelly

Attorney Stephen Jessup:

Kelly, I don’t think they would intentionally lie as it would be hard to conceal it as your whole claim consists of a paper trail for the past 8 years. That being said, being stupid and uninformed as to the information in your claim- that is more than likely from what you are saying. Have you spoken to the doctor that allegedly returned you to work? Quite often when a new claims manager gets onboard they seem to be intent on finding ways to deny claims, but with the information you provided I believe they would be hard pressed to find a basis that would “stick” at least in the long run. Please feel free to contact our office to discuss your claim in detail.

Kim:

My dr has not released me to go back to work,but the short term Dr’s say there is no reason why I can’t so do i go back to work even though I have not been released from my dr

Frustrated:

My husband has been approved for SSDI retro back to November 2015 when he went on STD and subsequently LTD. He got his award letter in March of 2016, and officially quit his job in May 2016 but was out of work at that time.

His LTD company has all of the information about his back injuries and also he had to have a cervical laminectomy due to severe degeneration in 3 discs. The Dr. he saw did x rays on his back to look at his old back surgeries and also had an MRI done. He has degenerated and has constant pain in both back and neck. He will be 55 in January and SSDI knows he was an electrician for about 30 years, cannot be rehabilitated to learn a new vocation and falls under their guidelines for Disabiility. His LTD has record of this too.

He no longer is seeing a Dr. for his condition. There is nothing they can do to help him and he is permanently disabled according to SSA.

Question is….why are they sending monthy APS forms when his Dr. already explained his condition and that he is permanently disabled? It is a long form and it costs money every time they have to fill this out.

He did have an attorney to help him get his SSDI. Should he contact him and also can this attorney write a letter to his LTD ins. company?

Thanks in advance for your help.

Attorney Stephen Jessup:

Frustrated, there is no such thing as a “permanent disability” as it relates to a private or employer provided policy and the carrier has the right to request updated proof of ongoing disability- to include medical records and claim forms. It may be possible to get the carrier to decrease report requirements but there will almost certainly still be an ongoing reporting requirement. Please feel free to contact our office to discuss your husband’s claim further.

Emily:

My employer has short term disability insurance. I am pregnant the work told me they could not accommodate my normal pregnancy work restrictions on the position i am on so they put me on disability at 16 weeks. Disability compony said i had to renew my clam after 2 months later. Now insurance company keeps moving my claim to different departments and say that their is no medical reason for my disability and that the work says i cant work but my doctor never said i couldnt. Yes my doctors never put me on it in the first place. I asked if i should go back to work they said no. What am i supposed to do i can not afford to live with out pay or pay insurance if i am not getting paid. I am at 33 weeks so i still have a nother month till baby comes and 6 weeks after that?

Attorney Stephen Jessup:

Emily, you do have an interesting fact pattern in that the doctor is not certifying any type of disability. Under a disability policy there will be a requirement that your condition prevents you from working, and that it be supported by the doctor. Have you discussed with HR the issues you’re having with the disability carrier?

Marlene:

My name is Marlene and I had complete knee replacement surgery 6 weeks ago, my short term disability paid me for 4 weeks and then stopped paying me saying I had to return to work after 4 weeks. I still have swelling of the knee and my doctor wouldn’t release me to go back to work. Is this legal and is there any recourse to take against the insurance company? I have been an employee at my company for over 20 years and have paid my Short Term Disability weekly with no previous claims.

Attorney Jay Symonds:

Marlene, to continue receiving STD you must establish that you meet the Policy definition of disability. It’s unclear from your question whether this is a self-funded salary continuation plan or a fully funded insurance policy. There can be a meaningful difference between the two. In some cases the claims administrator will rely on what the average recovery should be and try to enforce that absent clear medical evidence from your providers that your specific situation requires a longer recovery period. It will also depend on the type of occupation you have. I suggest you contact our office and speak with one of the attorneys to address your specific questions regarding your claim situation.

Sandra B.:

I’m going out on maternity leave in a week in California. My STD policy refuses to cover me until after I have the baby. My doctor has written me out of work, I have gestational diabetes and I am a veterinarian and unable to perform my job such as lifting 50 pound pets, performing surgery or being on my feet for 10 plus hours a day often with no breaks or food. I told my STD provider all of this and they refuse to cover and said that it doesn’t matter that I cannot safely continue my job that I must continue to work if I want to get paid as they do not consider being pregnant a diasability despite me falling under the legal definition of disability in California.

Attorney Stephen Jessup:

Sandra, if your policy does not cover pregnancy (which is rare) then the carrier may be right. We would need to see the policy to determine what your rights are under same. Additionally, California does provide state based disability that you should look into. Please feel free to contact our office to discuss your STD situation in greater detail.

Tuesday T.:

I have a terminal cancer. I found out in March. The insurance company paid disability benefits until June. They are now saying people with cancer work and there is no reason to extend the claim. My Onocologist stated on their form I could go back to work when I felt ready. I don’t feel ready yet. I am still receiving chemotheraphy. They denied the claim stating people with Cancer work. They are asking the doctor what is the anticipated return to work date. The doctors response is she has a terminal cancer. It feels like they are going to deny the claim because the doctor did not provide a return to work date. When I asked him about it. He said he cannot determine that because he does not know.

Attorney Stephen Jessup:

Tuesday, yours is one of the more egregious denials I have heard. Please contact our office to discuss the denial and how we may be able to assist you in getting your benefits restored.

Michae:

My Father-In-Law had a stroke in December and was placed on disability. He has comorbidities that were left unchecked prior to his stroke because he never went to the doctor. The Dr he was seeing is actually a PA. She would not release him to return to work because of his diabetes until June. The disability company is denying the claim stating he could return to work and no sufficient data was provided to show he shouldn’t. The PA has been very difficult to get paperwork from and kept submitting stuff last minute after multiple calls hounding her to get the paperwork in by deadline. It seems to me this is more of a issue with the PA who wasn’t either tracking my FILs condition appropriately or wasn’t doing her job on getting the information in. We believe he returned to work about the time he should have however he could have started a few weeks earlier. They have recently denied the Appeal. I don’t know if this should be addressed with the PAs office or the disability company. Honestly I don’t feel like the PA was doing her job to get information to the disability company.

Attorney Jay Symonds:

Michael, assuming this was a Short Term Disability claim the administrative requirements are significant and ongoing given the week to week payment of the claim. A non-responsive treatment provider can significantly hamper a claim and the timeliness of payment. Although your FIL is now back to work you don’t want a repeat of this situation should he go out again in the future. A conversation with the PA is probably wise but also understand that the family may need to be more involved (i.e., pick up and submit the records) to ensure all that needs to be done is getting done in a timely manner. Should the need arise in the future feel free to contact our office and speak with one of the attorneys to address specific questions regarding your FIL’s situation.

Suzanne W.:

Hello. I had back surgery May 31 2018 and have a return to work date of Sept. 20 2018. My problem is that The Hartford at work approved my STD until August 18 2018, when I applied for an extension their response is that it is suspect for my Surgeon to have given me the 4 months off BEFORE my surgery even though my workplace insisted on an exact return to work date and due to my physically demanding job they decided on the extent of my leave so I can return without any restrictions as required by my workplace. I have on multiple times tried to contact The Hartford at Work group but they haven’t given me an extension or a final decision, it has now been 2 weeks past the end of my approved medical leave. Is there anything I can do? No money coming in.
Suzanne W.

Attorney Alex Palamara:

Suzanne, if there is no number to reach them out, you need to start sending letters to them via certified mail and fax. Your excuse for why the surgeon took you out for 4 months certainly sounds reasonable. Hopefully they will listen to logic and act reasonably themselves. You may wish to put what you are stating here in writing and fax/mail it to them immediately. If they don’t pay you the final month of benefits, you may have to appeal their decision which will not be a quick process unfortunately.

Margaret:

I had been taking off of work for my hand therapy for my arthritis and lupus for 3 years, I’d never had any problems of getting paid out for my 3 months off. I do hand therapy for 2 and a half months, and my doctor wants me to do my new hand therapies I’ve learned for the other 2 weeks at home before returning to work to rest my hands from therapy for awhile.

The insurance company refuse to pay me for my other 2 weeks because they felt that I had no restrictions to go back to work and finished my therapy. I had informed them that my doctor I had retired and i had a new doctor in between my therapy, but when they had their doctor contact my new doctor that informed them that he had just learned my records and that the other doctor had requested this time off, but he told me that when their doctor called him he asked him questions like they were giving him choices to pick from and not his opion on me. He also wrote a letter saying that to them, but they still refuse to pay me those 2 weeks. Do you think I have any case to try and collect my money? This happened in December Last year. TY

Attorney Rachel Alters:

Margaret, you would need to file an appeal of the denial of your STD benefits within 180 days from the date you received it. If you did not file the appeal you should contact the insurance carrier and ask if they would accept a late appeal.

Confused:

Confused. I was taking out of work by my doctor for depression and anxiety. I was approved for STD by the insurance company. My doctor extended my date to return to work and after reviewing my psychiatrist report I was approved for the extension. Now my psychiatrist has extended my date again for the same reasons but I got a new case worker and she said my. extension has been denied and claim will be closed. Mine you my visit was August 10. I was approved until August 31 and I called in this morning to check my claim status and was given this information. I am confused am I to go back to work even though my Dr has not released me.

Victor Pena:

Confused, whether you are capable of returning to work is a decision to be made between you and your doctor. If you have already been approved to August 31st then you should be ok unless your doctor has extended the return to work date beyond that date in which case you should have your doctor provide support for his opinion.

Worried Wife:

My husband has stage 4 renal failure. He has been declared end of life. He is filing his SSDI and we have no doubt from what we have been told it will go through.
Then he called his HR person to start the claim for his LTD only to be told he can’t file because he doesn’t have STD. She said they require you to have the STD to use the LTD and most people are fired before they get the LTD approved.

No one ever told him he had to pay for the STD in order to use the LTD. Can they do that? He has been paying this for almost 20 years. He dropped the STD 3 years ago due to budget issues. I can’t get any answers from google to the simple question. Can they force you to buy STD in order to get the LTD?
He has paid for the LTD the entire time.

Attorney Jay Symonds:

Worried Wife, the only requirements to LTD are those set forth in the Policy. You should request the Policy in qwriting from the HR group as the employer is required by statute to provide the Policy. Typically there is an elimination period which is the amount of time you must be disabled before LTD benefits will be paid (e.g., 90 days or 180 days). The elimination period usually runs concurrent with an STD claim and maximum benefit period. I suspect your husband’s HR contact is wrong and he/she certainly cannot prevent you from filing an LTD claim. You should request the LTD claim forms and submit the LTD claim. I suggest you contact our office and speak with one of the attorneys to address in more detail your specific questions regarding your situation.

Concern individual:

I was taken off from work by my employer due to they wouldn’t or couldn’t accommodate to my restrictions made by my doctor, should I get approve for my LTD, due to the fact my doctor is not the one to release me. I have surgery next month, been off from work since November 2017 due to an injury that occurred on the job.

Frustrated:

I was taken off work as a nurse after my foot began swelling and causing nerve changes such as numbness. I had testing done that showed nerve damage, and my doctor restricted me from a lot of activity, including walking or standing for long periods as well as no driving. I am a visiting nurse. My STD went over fine, but my LTD is not accepting any of my proof. They have requested the same visit notes over and over from all 3 drs (primary, foot, and nerve). I have sent them all the requested papers as well. It’s going on 3 months with no payment, and with no money coming in, I either need to go to work or have my house start being foreclosed on/utilities shut off. Who do I call for help getting them to approve my claim? They have extended their time frame 2 times already for a decision.

Attorney Alex Palamara:

Frustrated, I am so sorry to hear of the ridiculousness that the insurance company has put you through. Please contact me immediately so that we can discuss your claim. Your claim is likely governed by the ERISA laws so the insurance company does have a deadline to provide an answer on your LTD claim. Please call me so that we can discuss your claim, the ERISA laws and how we can assist you. I look forward to speaking with you.

Concerned friend in Massachusetts:

A friend of mine is in stage 4 renal failure. Shes been on STD but they have denied her claim stating they needed the update from her Dr and her claim will be approved. She contacted her Dr and they said they faxed it over. She called Sedgwick and the told her they got it and that it should take about 7 business days for her pay. She called back on the 8th business day and her claims person told her it’s still being denied and that she has to appeal the claim. On 12/10/18 she got surgery for av fistula for her to start dialysis and can’t lift over 10lbs per Drs instructions for 4 months do to the healing process. Is there any course if action besides going through her HR to get her STD approved? Concerned friend in Mass

Attorney Cesar Gavidia:

Concerned, your friend should contact a disability insurance attorney immediately to discuss her options. Since she has been denied she will be required to appeal Sedgwick’s decision; however, she should not attempt to appeal herself since she may be limited to only one appeal and if it is denied any potential mishandling of the appeal could affect her long-term disability claim and the outcome of any future litigation.

Angel:

My husband started drawing STD in May 2016. He was unable to file paperwork. Initial diagnosis was bi-polar, severe depression, mood swings, anger outbursts, poor decision making, problems interacting with others, etc. His doctor felt he needed to see a specialist. I went above and beyond to provide them all paperwork and it is a constant struggle to get them to pay. the policy limits most mental illness to a two year policy with the exception of organic brain diseases and Alzheimer’s. According to his physician and online bi-polar is an organic brain disease. He also has other conditions in which his doctor is specifically stating that due to high blood pressure, GERD, high cholesterol, gout etc. he is unable to work. One issue I have is that no handbook was provided to me regarding the policy, I just did as instructed. After STD ran out and he moved to LTD, they required that he file for disability at the Social Security ,office., in which he won. The kicker is they are issuing me check stubs minus the SS amount and say I owe $18,000 from STD and LTD they paid while he was out.

After researching, I understand that if the company pays for the policy, you are required to pay the funds back if approved for disability, however he worked for the company for 12 years, contributed to the STD and LTD plans as well as paid for the buy up amount. Not being provided a handbook on the policy after asking numerous times, dealing with the company that handles disability has been a pain the the rear end. They say he signed a piece of paper stating he would pay it backout from back pay of SS.This is untrue because I have kept diligent records and they cannot or will not provide me a copy of this paper. I am in the process of appealing, but do not understand why you pay out of your check a portion of the policy plus the upgrade. What is the purpose of having STD and LTD.

When I received SS, my company did not ask me to pay back I look at it from this scenario. When he dies, will I have to pay back his life insurance if I get survivor benefits and am I entitled to the money they failed to send me, but not the check stubs and is there away to recoup on my tax return in any way? Thank you for your prompt attention and I appreciate your guidance. A final note: I have had to appeal many times because they have their clinicians evaluate if he is able to return to work or not. His doctor’s say a definite no, however the clinicians that have never even spoken to him say he is able to work Also at the top if a company pays, you have to reimburse, but if you pay, you do not. I need assistance. I am over y head. This is an International company based from France, offices all over the US with their American home office in Palatine, IL. Our residence is TN. Please advise. He bought his home out of college, which we are about to loose, scramble for food because we are not eligible by less than $100.00, down to one car. When it rains, it pours.

Regards,
Angel

Attorney Alex Palamara:

Angel, I am sorry to hear all of the troubles you are having with the insurance company. Unfortunately, most group insurance policies allow the insurance company to “offset” other income benefits claimants receive. In your scenario, it sounds like Social Security approved disability benefits after STD and LTD were approved and as such an overpayment is owed. I have heard the reason why must group policies are so affordable (the monthly premiums are so low) is because the “offset” provisions (as well as the laws that govern these policies).

Whether he signed the paper or not, the overpayment will likely be odd under the terms of the policy. If the insurance company denies his claim or if you have any troubles, please do not hesitate to contact us for a free consultation.

Eve:

Hi there!

I was on STD last year and they just paid me on November 2018. I asked my case manager on STD if i need to send in new medical forms to support for my LTD and she said no need and she will process my LTD right away since it was too late already (her fault) and I thought she is still my case manager for LTD coz she said she will process it right away coz its been too late already so that i will be paid. November and december passed but i never heard from them about my LTD so I called after new year.

On January 2019 I received a denial letter dated january 25. My case manager advised me to book an appointment to my doctor right away and get medical records that I have not been submitted and she said appeal as soon as I have all the records. I am so confused that they approved my STD for the injury I got from work but denied my LTD? It’s almost a year that I’m not working but I’m not receiving anything.

Attorney Jay Symonds:

Eve, I suggest you contact our office and speak with one of the attorneys to address your specific situation. They will need to see a copy of the denial letter and your Policy. Under the federal statute that governs your claim the insurer must provide you up to 180 days to file an appeal.

Nicole:

I found out I was pregnant in May 2018, at 18 weeks my high risk doctor told me that I could not work because of my high blood pressure and high proteins, I started to get short term disability in sep 2018 until Dec 2018 and my employer advised me to make a claim for long term disability because I still had several months to give birth and 6 weeks after delivery.

My problem is that the disability company is still asking for medical records and in 2 weeks I am supposed to return to my job and when I call they keep saying my claim is under investigation, it’s been like this for almost 3 months. If it gets approved, would they have to pay for the months the claim was submitted?

Victor Peña:

Nicole, unfortunately the carrier can take over 3 months to review an initial claim. In an ERISA governed claim they have 45 days with the option of taking two 30-day extensions. If they approve it they will pay the claim retroactively to the day benefits should have started even if you return to work.

Avi:

Hello.

My short term disability was approved and now it’s been two months and they are sending me a letter that it was denied, also asking to pay back what was paid out. Is this even possible?

Attorney Jay Symonds:

Avi, it sounds as though additional information or documentation was discovered that altered the company’s initial determination. I suggest you contact our office and speak with one of the attorneys to address the specific questions you have regarding your situation.

Confused Claimant:

I was in a car accident and suffered a herniated disc. The same disc is severely degenerating. I have been out of work for almost 8 months. I used all of my STD and it is now rolling over into LTD with Unum. My doctotor did not release me to work. Unimpressed delayed my LTD claim. They requested tons of paperwork (which they received), and all of it showed I sustained an injury in the car accident. Unum then requested a call with my doctor and I feel they bullied him in releasing me back to work. So my doctor has released me to work, however my organization approved my ADA claim through the rest of this month. How is it that Unum can tell my doctor to release me for work when I know I am no where near capable of performing my job? How are they able to make the decision that I should return back to work without my input?

Attorney Jay Symonds:

Confused, it is not uncommon for the carrier’s consulting physician to contact a claimant’s physician and manipulate the conversation such that it benefits the carrier. Unfortunately, once your physician makes a statement like this it is difficult, though not impossible, to overcome that on appeal. I suggest you contact our office and speak with one of the attorneys to address the specific questions you have regarding your situation.

Bobby:

Hello,

I am in the extended period of eligibility for SSDI. I returned to work and after 9 months have to apply for std which I have from my employer. I have a mental health related illness. My psychiatrist fully supports my std claim. Is it very likely the STD will get approved and as long as my doctor continues to support the claim I will receive STD for 6 months which is the policy term? I am thinking since I was approved for SSDI in the past it would be very difficult for them to deny the STD claim. The insurer is prudential.

Thank you

Attorney Cesar Gavidia:

Bobby, it depends on your disability insurance coverage. In order to qualify for benefits you are required to meet very specific term and conditions which you will only find in your disability insurance policy.

Renee:

I had a partial hysterectomy – during surgery the doctor discovered I had stage 4 severe endometriosis. The doctor cleaned off my remaining ovary and surrounding organs as best as possible in the hopes that I can live with the single ovary until natural menopause. The Hartford approved me to be off 4 weeks. The doctor stated that I had to be off 8 weeks. During my 8th week appt, the doctor noted my complications from the endometriosis. I was out 2 weeks additional after this. The complications were extreme pain. This included passing gas, bowel movements, sitting for long periods (over an hour), etc. I was on narcotics throughout the day.

I had this additional information sent in to the Hartford. Their conclusion was that pain was subjective and I should have come back to work after 4 weeks. How can I fight their conclusion? I have a history of anxiety and depression and this has been causing me so much mental distress. My work is coming after me now for the money paid while on leave that was now denied. Please advise or help!

Attorney Cesar Gavidia:

Renee, if your claim has been denied by Hartford they should have provided you with a denial letter explaining the reasons that it believes you do not qualify. The letter should provide you with the timeframe you have in which to appeal that decision. You would challenge and address Hartford’s denial through the appeal process that it provided under your LTD Plan. Please contact us to discuss how we can assist you with your appeal with one of our disability attorneys.

Bobbi:

I hurt my knee at work back in dec 2018 ,turned it into workman comp but all they did was x-ray and ibuprofen although I could barely walk on it. They said I had a bad sprain. I was released from work comp but pain and swelling continued. I dealt with it until May 2019 when I finally saw my PCP and he put me on short term leave and ordered MRI which showed torn meniscus. He sent me to Ortho specialist on April 9 who prescribed me another anti-inflammatory. Didn’t get better so surgery was done may 21. My follow-up was June 10 and I still have alot of swelling and trouble walking for extended periods. My PCP put me off again ,until my next Ortho appointment July 22. I had no issues with my claim being approved or with payments until my last follow up ,I’ve not received payment since June 7. I’m confused on y it could still be under review when I just had surgery. Recovery from surgery is 4-6 weeks ,my Ortho Dr said sometimes up to three months. I should add I had a horn repair,partial meniscus removal,and plica band removal .

Attorney Alex Palamara:

Bobbi, I am sorry to hear all that you are going through. Often, there is no explanation for an insurance companies delay in approving your claim. However, they may be awaiting records from your treating providers or from the surgical center. One thing you must do is submit all supportive records ASAP. Please feel free to contact us at your convenience so we can learn more about your claim and assist you any way we can.

John G.:

Back in June 2018 I was diagnosed as having a retroperitoneal soft tissue sarcoma/RSTS (LEIOMYOSARCOMA/LMS) of the inferior vena cava (IVC). I was started on 30 radiation sessions in preparation for surgical excision, medically deemed the ONLY curative for RSTS LMS. On 11/05/2018 I went on 12 days FMLA leave which eventually rolled to STD(AETNA) on 11/19/2018, eventually turning to LTD(AETNA) on 5/23/2018.

Post radiation the surgery was scheduled for November but was aborted when the anesthesiologist attempted to start the anesthesia in my right jugular vein (RJV). Surgery canceled as the RJV was discovered to have a large blood clot, which turned out to have been caused by a biopsy of my thyroid 7 days earlier. I was then scheduled for 6 six cycle of chemotherapy in order to attempt to keep the RSTS LMS from growing in order to eventually perform the surgical removal done post the chemo. The last (sixth) chemo cycle was completed mid February 2019. Assessment for surgery began. After extensive tests and physician consult with experts on treating RSTS LMS form other countries, it was determined that due to the radiation and chemo that my liver had been damaged to the point that surgery was more of a threat than not so surgery was once again nixed.

As my leave agencies, FMLA/AETNA/employer HR, continued to request and obtain pertinent information from all of my physicians, the FMAL /Hr determination interpreted from my physicians responses is that my recovery is “indeterminate”. Because of this my corporate HR will not approve an LTD extension past the current 0730/2019 end. Further I was told that I either had to return to work 08/01/209 or resign.

While I feel strong enough to return to work at this writing, based on all the existing medical knowledge concerning my condition, it is the experience for all known cases that RSTS LMS will progress rapidly and in fairly short time I may well be negatively affected to the point that I may no longer work. My question is, given that I am medically disabled still per my physicians, on what basis could the HR deny my extension based on the statement “Now that your recovery has been deemed indeterminate”? THANK YOU

Attorney Jay Symonds:

John, approval and/or denial of FMLA leave is an employment issue for which you may want to consult and employment attorney. The U.S. Department of Labor’s Wage and Hour Division (WHD) is responsible for administering and enforcing the Family and Medical Leave Act for most employees. If you have questions, or you think that your rights under the FMLA may have been violated, you can contact WHD at 1-866-487-9243. If you have questions regarding your LTD claim with Aetna, I suggest you contact our office and speak with one of the attorneys to address the specific questions you have regarding your situation.

Eric:

My short term disability was denied by a independent Medical Examiner that I never meet or even talked too. All they did was talk to my primary doctor about me. Is this the way it should go a doctor that never sees someone can make a decision about someone?

Attorney Rachel Alters:

Eric, unfortunately the insurance company is permitted to hire a physician to perform a paper review of your records and determine that you are able to work. If you are going back to work before your LTD kicks in then you should appeal on your own. If you are going to roll into LTD then I would consider hiring an attorney to assist you with your claim.

Colleen:

I have combat PTSD and have been out of work since 8/8. I was in the hospital on the Behavoir Unit for ten days and now I am doing an intense Partial hospitalization. The dr said I can’t go back to work until 10/1 and that would be parttime. I got short term disability from a private company through work cause I was afraid this would happen but they denied me due to mental illness. Do I have any course of action?

Attorney Stephen Jessup:

Colleen, to clarify did the insurance company refuse to provide you coverage because of your medical history (actually give you a policy) or did they deny a disability insurance claim you made under your policy?

John:

I have short term and long term group insurance from my employer. Was approved for short term disability, now it has ended, filed for my long waity on the insurance company decision and waiting for a surgery next month. My employer call me wants to fire and rehire me till I’m ready to return to work. Can I be denied my long term?

Attorney Cesar Gavidia:

John, even if your employer decides to terminate your employment and rehire you later, possibly ending your LTD and other employee benefit coverage, you may still apply for long-term disability since your claim begins from your last day worked and at that time you were a covered employee.

Surgery sure but not recovery time?:

Hello,

I had peroneal nerve decompression surgery on 5/6/19 and I was out of work for recovery from 5/6 to 5/26 at which point I was still having severe pain and spoke with my doctor who took me off work completely until 6/3/2019 and then released me to work only 1/2 days until 6/25.

Sedgwick approved my disability from 5/6-5/26 and then denied my recovery time from 5/27-6/24. I then filed an appeal including a note from my doctor indicating that my surgery was not typical and I didn’t present with typical diagnosis; my surgery was experimental peroneal nerve decompression. I’m still having issues with my leg and the pain is still bad, since then I’ve had another procedure done on my leg that I didn’t take time off work for.

How can Sedgwick approve your surgery and then deny your recovery time? Sounds like my appeal is also going to be denied.

Attorney Rachel Alters:

Surgery, unfortunately Sedgwick does a lot of suspect things when managing claims. Sedgwick isn’t liable for paying your benefits, it’s your employer that’s on the hook if you have to litigate. If your appeal is denied you will need to find a lawyer in the state you live in to sure you employer.

Richard:

My doctor said I could go back to work in carpentry with restriction! don’t take 20 lbs in weight! The insured company stopped my payments even after I took a MRI scan and even the doctor said I was out of work. Does the company pay me back?

Attorney Rachel Alters:

Richard, you would need to file an appeal if the insurance company denied your claim. If you have questions you can contact our firm at 888-729 3355.

Too much surgery:

I submitted my claim September 27th because my doctor requested pre-surgery cleanse. I did not want to be at work with nausea and diarrhea which is a symptom of the cleanse. My surgery for a hysterectomy and hernia repair and bladder repair was scheduled October 3rd. I was told by Aetna they could not approve September 27th through the 2nd of October because a cleanse was not medically necessary to them even though it was prescribed by the physician. I then had a breast reduction October 17th. I was told my claim would be approved October 3 until November 13th. I have been having trouble after both surgeries with my energy level, focus, headache, exhaustion, constipation, nausea and dizziness. I also have trouble driving because of the pressure on my stomach and pelvic area and my breasts are still extremely swollen. I have asked my physician to send my medical records and per Aetna (through my employer) I am required to go back to work even though it has only been 4 weeks.

My claim was denied because I have a sedentary job. I have explained to my physician that I have a very high demanding position that requires me to almost perform job duties of four different people. I also have to drive an hour and a half to get there. What options do I have because I’m physically unable to drive an hour and a half to work and I currently can’t sit for over 2 hours at a time. I’m still getting rides just to my physician’s office which is less than 5 miles away. My recovery is taking longer than I imagined.

Attorney Alex Palamara:

“Too much surgery”, I am sorry to hear of your issues and of your claim denial. There is an appellate process to challenge this denial by Aetna. We are always available for a free consultation. Please call us and we will request that you send us a copy of the denial letter. We look forward to speaking with you.

Kristy:

I truly hope someone on here can help me. I work for Sedgwick and they also manage my STD benefits. In June I was approved for my STD benefits for my mental health condition, however they contacted me a month later and said my leave is no longer supported based off my provider using the word euthymic to describe my mood that day. My provider immediately sent the claims specialist a 3 page letter and explained that I do not suffer from depression so that is why she used that term. This has not helped, I have been appealing every month going forward with more and more documents from my providers but their outside hired provider does not support my disability. I got a call from my claim worker last week and said one day would be supported because I had a panic attack while in my Doctor’s office, so my question is how can a claim be based on one day in the office, I struggle with this daily and cant go to the hospital each and every time I have a panic attack. Please help guide me on what to do I’ve drained all my savings and I’m a single mother facing eviction I dont know where else to turn.

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