The question listed below was recently posted on our disability blog, but since it is a question that we receive on a weekly basis, we decided to make it a frequently asked question.
Thank you so much for this blog and your site. It is truly a resource for anyone with an ERISA claim.
From the start things are skewed when you have a “mental health” diagnosis. The inequities the mental health community has had to continually face is astounding. When you go to the State House & recruit a NAMIWALK team and your results yield $0 you know something is wrong. When you read a magazine Boston Proper & May is mental health month yet there are no charity events mentioned for mental health- you know there is a problem. All across the USA disability policies are allowed to have this 12-24 month limitation which is fundamentally unjust. When will Congress amend ERISA, so it can not blatantly discriminate against those with severe mental illnesses which are true diseases. Does anyone question this fact?
Politicians do not think this cause will look favorable in their CV, but I think
if they would just try on the cause they may be surprised with the high prevalence and huge cost to this society, why is it so off everyone’s radar? High prevalence and cost sounds to me like it really needs to be a PRIORITY. Realistically everyone is afraid of the man with untreated Schizophrenia even those in the mental health community.
But he needs compassion, services, medication and support & with treatment hopefully will be a responder, not treatment resistant, and his condition will improve. Instead an untreated schizophrenic man shoots dead his neighboor and the police beat to death another weaponless homeless man with schizophrenia. Could this country be doing a worse job for those severely mentally ill?
My first dealing with Aetna was through my denial notice which does not comply with the ERISA statute. There was no information regarding possibility of appeal or any time frame. There was only a phone number to call if I had questions. Needless to say, I am past the 180 days time frame which I later learned should have been on my appeal notice. And I am approaching the 1 yr limit for a claim mentioned in the SPD.
How many claim denial notices does Aetna mail a year? It is really beyond reproach to have an imcomplete letter with a time frame ommitted from someone with a mental health diagnosis? Motivation, responding in a timely manner is such a struggle if you have a mental health diagnosis so Aetna scrupuolously chose the right claim to leave off a deadline. Because I am barely functional at times so to actual even be able to complete the Appeal process for someone like me is a huge feat. I am ecstatic if I can get out of bed before half the day is gone, feed myself and shower at this point. I imagine countless of these claims go unfiled for just that reason. If you do not have a mental health advocate. I need to have someone stopping by to ensure I am completing this regularly.
To obtain a copy of my SPD, I had to contact my legislator and the DOL regional office. It was then that I received a copy by email.
And obtaining a lawyer is a huge challenge because not only is ERISA disability highly specific, but to also have successfully litigated mental health cases is virtually impossible. Will I be so fortunate to find a lawyer with these qualifications & who can take my case on contingency?
- ERISA background
- Successful long term disability mental health verdicts
- Willing to work on contingency
- and my year to file an appeal is 10/20/11
These requirements seem insurmountable to me.
I think the policy language is ambiguous, but I am not sure. The SPD and the Policy language do not agree.
Aetna is in the dual position of paying for the fund & having the discretion to decide eligibility of benefits. Therefore, there may be a conflict of interest.
It is clear to me that out of 2 year period that Aetna only obtained 6 months of my medical records. That does not appear that it would provide a fair and thorough review.
Aetna has required me to apply for social security disability which I was deemed fully disabled & Aetna immediately required my reimbursement of overpayment. Aetna will now be required to pay me my monthly benefit minus my social security award which is a financial incentive for Aetna. Thankful that I was approved for social security the first time, otherwise Aetna would have required me to reapply and appeal until I met their satisfaction.
There was no mention in my denial notice why Aetna did not consider my Social Security disability determination in my favor towards my disability claim with Aetna.
Was reading that the case could be tried in where I live, or the Plan is located or the fiduciary is located. That would include Circuit Court 1, Circuit Court 2 or Circuit Court 6. Does anyone know how to determine which Cicuit court favors
overturning ERISA 24 month limitation denials/termination of benefits for mental health diagnoses?
Appreciate any input. The clock is ticking and it is so stressful. And my illness is at its worse.
Unfortunately I don’t think Congress has the power to tell the insurance companies they cannot limit mental nervous claims. If Aetna failed to advise you of the 180 days to appeal, then you may still be able to appeal and file a lawsuit. I don’t know the exact number of claims Aetna denies each year, but based upon the number of Aetna Disability policy holders I speak to each year, I would estimate the number to be in the thousands. Aetna collects 500 million a year in disability insurance premiums. Overturning the 24 month limitation is not going to happen, but sometimes the mental health limitations are drafted in a manner that do not exclude certain mental illnesses. Additionally, if you have any other illnesses that are not mental, then you may be able to extend beyond 24 months.