It's like my Momma used to say...

[Dedicated_Dad]

... It's always somethin', never nothin'...

For those too young to remember, that's a quote from Rosanne Rosannadanna. I'm dating myself, aren't I?

I'm still stuck, still waiting. I have an appointment with the big-dog OS on 8/21. I found out yesterday that they won't do surgery until 8 weeks after a cortisone shot, which puts me out through 9/18. She said they were scheduling for late Sept. now, so... Still going to be stuck even longer than I thought. I am SOO tired of this...

I also learned that he did the cortisone shot for diagnostic purposes - apparently he does this a lot. If it helps, it tells him he's in the right area. He put it right into my infrapatellar fat-pad, it settled my knee down a good bit, so he knows that's the biggest problem.

I would appreciate any input anyone may be able to give in re: a different but related problem...

I have private disability insurance. They took my premiums for ~5 years, but now don't want to pay me. The last check I got from them covered me through 5/15. I got this check on ~6/20, with a letter saying "need more info from the Doc to pay any longer. He sent them notes on 6/26, at which visit he'd told me no work through 7/31.

On ~7/15 I called them, asking "where's my check." They said it would be sent 3 days later. I waited 3 weeks, heard nothing.

~10 days ago I called them again. The operator said someone had made a mistake - the last thing in her system was my call. She passed me to the "analyst" who is handling my claim.

He said my Doc's notes from 6/26 said I was "doing better" so ... They weren't planning to pay me any more.

(1) "better" and "good" are 2 different words.
(2) On this date, the same Doc said "no work through 7/31
(3) 18 days later, a truly eminent surgeon said "no work until further notice" and ordered me onto my back.

Somehow they think they're able to read the notes of the surgeon who operated on me, and examined me on 6/26 and declare me "able to work" when the guy who wrote the da*n notes said "no work for ~5 more weeks."

what??

Further, even if one buys their "logic", they owe me -- at a minimum -- for 5/15 through 6/26.

My mortgage payment is due, and I am BROKE.

This guy says they need records from SuperDoc, who is gone out of the country and won't be back for several weeks.

I've tried to be polite -- no point making them mad -- but I am about at the end of my rope. Today I got off the phone before I lost it on him, but apparently my hitting the "off" button didn't work...

I screamed "f((((ing idiot!!" and threw the phone. A couple of minutes later it was making the beeping "off the hook too long" noise... When I picked it up it was still counting minutes from my last call. No doubt he heard me screaming...

What can I do? They seem to have all the power, and know it. I'm stuck on my butt...

I sent this clown an e-mail with all the docs I have, but he claims he didn't get it. Says their e-mail system blocks inbound stuff until it's approved and yadda-yadda-yadda. Excuses.

Nice way to do business BTW -- demand more documentation, then claim you didn't get it, then blame some nebulous other person...

Short of driving there and shooting up the place, what can I do to recover power in this situation? As far as I am concerned, they took my premium payments for 5+ years and now are in default on our contract!

All advice is deeply appreciated...

DD

 

[Dedicated_Dad]

I just sent them the following e-mail.

Probably peeing in the wind, but... At this point if nothing else it made me feel better. I *WILL* be all over the promised agencies on Friday AM if they don't settle this tomorrow.

This is RIDICULOUS.

I *KNOW* my surgeon's notes talked about my extreme muscle atrophy. According to them, him saying "doing better" on 6/26 means they don't have to pay me pas 5/15?

RIDICULOUS.

=======================
Sir,

I've been polite, but am running out of both time and patience.

On or about 6/26 my surgeon told me I could not work through 7/31. I've sent you a copy of that document, and I know that his office did so as well.

Your company accepted payment from me for years, but now is not upholding their obligations under our contract. I've done what I was asked to do, and ensured my surgeon's notes were sent on over a month ago, but noone contacted me at all. It was only when I began to complain that I was given the excuse that "I was doing better."

As I have pointed out repeatedly, if [Company] wishes to argue that this terminates their responsibility to me -- which I promise will be a battle -- this does not negate your responsibility to pay me from 5/15 through 6/26. My current condition, further documentation from my surgeon, or any other documentation is irrelevant to this fact.

I have asked you repeatedly to do whatever was necessary to obtain payment for me through 6/26 in order to alleviate the financial pressure on me and give me time to obtain the documentation you need to continue my claim beyond that date.

At this point, as I have told you repeatedly, my mortgage payment is overdue, as a direct result of your company's failure to honor their responsibilities to me under our contract. I will vigorously pursue any and all legal remedies available to me as a result thereof.

Enough is enough.

If I do not hear from you to tell me that my check is on its way by close of business on Thursday August 7th, I will be contacting the [State] Insurance Commissioner, the Consumer Protection division, my Attorney, and any other persons or agencies which may be able to bring pressure on your company, first thing Friday morning.

Obviously I would prefer to live at peace with all people whenever possible, and you still have the opportunity to do the right thing and prevent this from happening, but I simply cannot wait any longer.

As you know, I can be reached at [Home#] (Home) unless I am out for a PT appointment, in which case I can be reached on my cell phone at [Cell#]. It's my sincere hope that you'll do what is necessary.

Sincerely,

DD

 

[Simon]

DD

The email is a good start especially reporting them to the regulatory agencies.

Here are my suggestions.

Even though the OS is out of the office, his staff is there. All doctors office, especially surgeons have at least 1 if not more people who handle insurance/disability issues. So call them tomorrow and ask to speak to the person who handles insurance appeals. Then write up a time line for them starting from when you first went out on disability and all the records and back up you have. They can also throw in the stress is having a very negative effect on your health and that will just delay your return to work.

If the office can't help, just get a lawyer and go after them.

Call the mortgage company immediately and tell them what is going on as the early you talk with them the more likely they will be willing to work something out.


Friends say insurance companies to this to see who will challenge them. I am also gearing up for battle myself. While on the surgery floor the hospital went round and round with them to approve inpatient rehab especially since I live alone and in a rural area. Well they finally got the approval for 7 days. The discharge planner and rehab doctor then started to file appeals to go beyond 7 days with no luck.

So I came home thinking I only had to appeal the last 4 days. Then I got the explanation of benefits from them and they rejected the whole claim.

GOOD LUCK and give it to them.

Simon

 

[Rowdy66]

Do not threaten to call the agencies you named. I have been where you are. Every single letter you send them should have copies and cover letters sent to each person you name and anyone else you think can help you. I worked for the state and wrote the head of my agency as well as her boss, the governor. Once they saw I was going to do what I stated, they complied. And Simon is right, there is someone in the surgeon's office who can make you copies of all your needed records. Keep copies of everything and send the copies. You need to start a file on all correspondence you send them and have a complete record of each piece of paper you send them regardless of how insignificant you think it might be. Documentation, complete, accurate documentation will win your case. Good luck. Rowdy

 

[Gretchendz]

Ok...my real life job deals with issue like this....

My general advice:

1) As much as you possibly can, keep them in touch with one doctor only. I know this may not always be possible, but try to minimize this. The minute you have multiple doctors involved the insurance company will try to use little variations in the reports against you. The insurance company's interest is in not paying you (I'm sure you know that by now!)

2) It is often worth the money (should be only a few hundred dollars for this is you do all the homework) to hire an attorney for the sole purpose of writing a semi-threatening letter or two. If by chance you were represented by a union, they will often provide this service free of charge to you. Most attorneys won't charge much to write such a letter (provided you bring in all the documentation). The letter coming from the attorney tells them you will not go away quietly and makes them more likely to look seriously at your claim.

Good luck!

 

[Josephine]

Despite all it's various shortcomings, I am so pleased we have our NHS. This kind of stress is the last thing you need in your situation. I am praying for you Dad.

 

[carolinagirl]

I can relate. I had my RTKR July 3rd. Had all my short term disabilty papers filled out my both me and my OS and turned in to our "insurance person"
the week of my surgery. The only thing I have heard is how they are having to review and request more info from my OS. They have sent me the same form TWICE now to sign and return. Mind you, I signed this same form BEFORE surgery also!! I think it is their way of trying to get around paying.
I will be back to work before they decide anything. I return to work August 18th. But, I won't let this one go either! I figure they owe me for the month of July and up until August 17th!!!!
I plan on contacting our insurance person the day I go back to work!
Now to use a good ole southern saying, if I don't keep after them "there ain't a dogs butt in Georgia"!!!!!
I know that if we hee hawed around about paying our premiums the way they hee haw about paying us they would cancel our insurance in a heartbeat!!

 

[DaleMc]

Here is another good one for you. We had to pay a copay to the hospital before they would allow the operation. After I checked in for surgery they asked my wife for $991. Which was above what it should have been but she paid it so there would not be any issues. Now that it is over and the insurance company has paid them the hospital owes us over $500 and they said it could take up to 6 months to get back because they have to audit the account and make sure all the numbers are in sync. Sounds like a real ripoff to me.

Dale

 

[Dedicated_Dad]

This jerk just called.

He says that my OS's notes from my 6/26 visit say I have ROM of 110 degrees, and this is enough for a sedentary job.

I must have asked him a dozen times how this justifies their not paying me from 5/15 to 6/26. All he could do was stutter and say "this is why I need these records."

I finally told him that I have been as polite and cooperative as I know how to be, but I am not t going to play with him any more. If their position is that I am able to work as of 6/26 -- in spite of the two -- **TWO** -- surgeons who have operated on and examined me saying otherwise, then we could fight about that later, but it did not alleviate their responsibility to pay me through at least 6/26. I cannot fathom, sir, how you think you can read what a Doctor wrote and override his medical decision as to what I am capable of doing - I cannot fathom what makes you think you can read his notes and order me to work when he, who actually examined me, says I cannot.

Further, please be advised that I have a credit score of near 850 and have worked very, very hard to get it and keep it there. At this point my mortgage payment is overdue because they are in default of their contract with me. If this harms my credit rating you can be sure that I will see that I am compensated. I have never made a late payment until now, and I am currently overdue because of your refusal to honor the terms of our contract.

He still wanted to argue "I'm trying to help..." No sir. You're trying to come up with an excuse for not paying me, and I am not going to play any more.

At a minimum, you owe me for 5/15 through 6/26. IF I don't hear from you by 5PM today to tell me a check is on its way, I've already told you what I will do at 9AM tomorrow. Goodbye. <click>

This probably did me no good at all, but if nothing else it made me feel better. I REALLY don't need this BS...

DD

 

[Skeet]

I am so thankful I had no real issues with insurance or disability... it was all through my employer, HP. I am praying right now that folks will see the truth in all this, pay you through 6/26 and then reinstate your disability from that time until such time as your disability either legitimately runs out or your doctor says you may return to work. I also pray the mortgage company is compassionate and that this mess in no way negatively impacts your credit score. Lastly I pray comfort, strength, and peace for you as you deal with all this. God bless you!

 

[AlaskanTKR]

We have double insurance through my husband and my jobs. So far things seem ok. I have been fortunate - either that or its that we live up in AK. The insurance seems like while they take a long time to deal with things they do. I have learned that if I get any statements from the hospital, dr or anyplace else I send them back and write on it that we are awaiting return from insurance. Then if necessary I get on the phone with the insurance company. We finally just settled up with our dentist - for services back in December!!!!!!!! Needless to say they now owe us 253.00 that we overpaid in case ins didn't cover certain things. But up till June insurance was still screwing around. Everytime the dentist sent us a statement I would send it back with a note stating the isnsurance still had not taken care of it. No problems - its like they just wanted us to know so I did.

I didn't need to deal with disability or WC this time. I was off from work anyway and hopefully I will do fine going back this Tuesday. May not be my best - but I will hang in there. Workmans comp may be an issue - but I hope not. My original injury was due to a snowmobile incident, followed by 3 different workman's comp issues on the same knee due to my job then followed by another stupid move on my part and finally just a winter of stumbles. Insurance has tried to push it to WC in the past but inreality it is Insurance.


I try my best to keep all the paperwork together - but there just seems to be sooooo much - Loved the Anestheolgist bill. Surgery was 7/14 and his bill was here on 7/20 and dated 7/15 - His service alone was 1600.00 UGHHH. What do they get - like 500 bucks an hour to pass gas??? I knew I should have gone into medicine!

Oh well - I guess we all really need to cherish our new knees!
I know I will-
Marianne

 

[Dedicated_Dad]

I am grateful for all the good wishes.

Having read up on ERISA (wanna puke? Google that phrase. Any illusions you had that this system might be fair will be GONE.)...

This is just SICK.

Anyhow, I'm going to take a different tack. I've already written the VP of HR at my former employer - the ones who provided my disability benefit. We're in negotiations now in re: all the unpaid overtime and wrongful dismissal. She's got good reasons to know that any added pain or stress on me right now is DEFINITELY not in their best interest if you know what I mean...

The amounts of the disability payments they owe me are quite small potatoes, especially compared to losing the business of this big, nationwide company. She'll have leverage with them I don't have.

I'm not hard to please - pay me now through 6/26 and we'll settle the rest when SuperDoc comes back from vacation.

One thing is for damn sure, though: After this experience, and having read up on ERISA I will be conducting all future communications with these people in writing and be very selective about what info they are sent. It's truly sick what they can get away with...

I would strongly recommend googling ERISA and reading up. You have to be VERY careful in dealing with these people or they can screw you royally and you have little recourse.

With the small $$ amounts (to them, though HUGE to me!) involved, no Atty will take this case on contingency. I can't afford to lose 1/3 of the 1/2 my usual income even if I could find someone to represent me.

I'm going to have to play their game and hope that Ms. VP can bring some pressure to bear on them in the short run and they'll get straight when SuperDoc returns, otherwise... well... Me and Mr. "Analyst" are going to have a score to settle.

I'm a loyal friend, honest to a fault, very forgiving of mistakes -- but ... Deliberately violate my trust and screw me like this? You REALLY don't want me as an enemy...

DD

 

[Dedicated_Dad]

I'm feeling much better today.

They're going to have to pay me sooner or later. I'm disabled whether they like it or not, and my upcoming surgery (or two) will prove this beyond any doubt.

Further, I think Ms. HR VP will be able to get them to pay me now for 5/15-6/26. This will buy me the time I need to get the rest of it straight.

Thanks so much for being there - prayers still deeply appreciated!!

DD

 

[Josephine]

That's what we're here for, Dad. Doesn't always have to be medical stuff!