Stalling Tactics To Avoid Appeal

Hi everyone!
     I hope you all are enjoying your holiday season. I know I have been doing my best to focus on family and friend gatherings and celebrations rather than typical daily life. However, I'm realizing that I can not simply stop working on important outstanding items so I'm rejoining the world today.

 It has been awhile since I've updated you about my insurance situation. When last I wrote, I spoke about ERISA and how the law is interpreted to give the client only 60 days to appeal a cancelation of benefits from long term disability companies. I also discussed how I sent in my appeal along with a second certified/signature required letter request for my entire case file to be sent to me within the month.

Yesterday marked day 20 of the insurance company signing for said letter and I have heard nothing. I decided to give them a call to check up on the progress of my request only to find out that although they had the letter in their system, and indeed signed for it 20 days ago, they did not have it marked as requiring any follow up. Therefore, for the last 20 days, the company has simply not been working on the request. According to the worker I spoke with (the one who signed the cancelation of benefits letter-- and sounded shocked to hear from me, but then smugly asked how my holiday was) they will send me all of the documentation I requested within 7-10 business days.  I'll believe it when I see it.

Just a reminder of why we need to follow up with companies even if we've gone to all the trouble to send certified letters requiring signatures.

This is not the first certified/signature required letter this company has actively avoided responding to, claiming it was mismarked in their computer system. Therefore, I'm 100% certain it's a common stalling tactic that they hope will cause the appeal to be sent in late, and allow the cancelation of benefits to stand uncontested.

I'm glad I sent the appeal in despite not having all of the information I requested, because at least the process has begun and I'm not panicking over when this box of documentation will arrive and if it will be complete. Let's say I receive the box of information at the 45 day mark-- what if it's not all there? How long would it take me or an attorney to accurately go through it?  Probably more than the week I would have left before I would need to send the appeal letter in and make sure it arrived before day 60.

At least this way, should this case go to court it is not an "easily dismissed on a technicality" situation now.

1974 ERISA Law

I've been thinking a lot about the 1974 ERISA (Employee Retirement Income Securities Act) law since I received my denial letter from the insurance company last week. (Which by the way,  yesterday I received the returned signature cards showing they received the certified letters for both the appeal and documents request).

The reason I've been thinking about ERISA is because it was noted in my denial letter and according to my research this law has been exploited by many insurance companies in order to no longer honor their obligations to policy holders. 

I found two articles/briefs that got me thinking about my own experience. Both are worth a read if you have some time. Specifically the second one that discusses exactly how this law is used against patients in insurance cases.

http://www.patientadvocate.org/index.php?p=443 

and

http://www.patientadvocate.org/pdf/ERISA.pdf

One thing I found surprising is in my own denial letter. The insurance company informed me I had 180 days to appeal the denial. However, with ERISA I really only have 60 days or a judge could throw out any future lawsuit regarding the case. 

I have a solid connection to a law firm willing to represent me, but I wanted to fully explore my options so I contacted a local firm that specializes in ERISA law. When I queried them I received a response back that this specific firm only represents the insurance companies with their knowledge of ERISA, not the patients. Of course large companies with large legal budgets are where the real money is, so from a financial perspective I understand that law firm's decision. I'm saddened though that this firm would use its knowledge to support companies known to abuse this law. 

The loopholes this law offers, I'm sure were unforeseen in 1974. However, over the years companies have discovered new exploitation methods using older laws. It's sad... and we're clearly at a point when these laws need to be changed. 

When I spoke to the insurance person who sent me the denial letter (before the denial was ever sent). He informed me this was "nothing personal"-- it was simply business. 

I would argue, "business" set up on loopholes and a year end bonus structure that encourages vilifying an honest policy holder, is very personal. Making up false claims about another human being in order to receive a year end bonus for saving the company money, is very personal. Trying to use intimidation tactics to harass a client because you know that client is not allowed a jury trial under ERISA, and you will never have to answer for that harassment, is very personal.

I am not a moral authority. I'm just an average human being whose integrity is being attacked by a company for the sake of money. And I'm wondering when the collective "we", as employees, stopped listening to our conscience and instead put all our trust in company policies meant to harm clients. 

I encourage anyone reading this to fully educate yourself on ERISA so you will have some basic knowledge should it ever be used as a tool against you. 

Denial Letters Without Using Facts

Earlier this year I posted a blog with a denial letter I received stating I was denied coverage, because.
http://themalformationofhealthcare.blogspot.com/2012/08/denial-because.html

No, I didn't forget to finish the above sentence. The denial letter I received said I was denied coverage "because." No further explanation.

It turned out the reason I received the denial was because of an inter-insurance-company problem having nothing to do with me. So when the insurance company didn't pay my claim, they had no reason for why it was denied, and therefore left the section blank. Leaving me to panic, call them, and wait until they cleared up their error and pay the invoice prior to me ending up in collections for something that should have been covered through insurance.

Ready for something to top not giving a reason for a denial.....

Drum Roll Please.....

Yesterday, the insurance policy I have held since I had to stop working due to my arteriovenous malformation and chronic myelogenous leukemia sent me a letter listing off several reasons why they have decided to stop honoring their obligation to my claim. They included not hearing back from my doctor (although my doctors name was spelled completely incorrectly and I can only wonder if she even received the documents she was asked to fill out). Partial information from a report done by a doctor who in a video taped interview stated he did not treat either condition I have. Video taped surveillance showing me go into a local business for 3 hours (without mentioning it was a dental office)...And the piece de resistance....

 because my oncologist informed the company that I was in complete remission from AML.

You can imagine my relief to hear I was in complete remission from a condition I was never diagnosed with.

Here's the portion of the letter:

Yes, this denial letter stooped so low as to deny my claim using completely false information.

AML is Acute Myeloid Leukemia. It is a really terrible blood cancer that is difficult to control. I have known two young adults who have battled this disease. One survived it and one did not.  AML is treated with aggressive traditional chemotherapy and often a bone marrow transplant.

I have Chronic Myelogenous Leukemia-- a completely separate condition that currently has no proven "cure" outside of a bone marrow transplant. Fortunately for me, as long as I take a daily chemotherapy pill my chronic leukemia is kept at bay in the body. It is not a traditional "remission" as suggested by this letter. It is a conditional cytogenetic response to a daily chemotherapy drug.

I sent in the appeal letter today correcting their misinformation and requesting my policy to be reinstated. Should this company deny the claim a second time my only recourse is to hire an attorney.