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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 21 opinions so far. Add your comment now.

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.

Attorney Victor Peña:

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.

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