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Short Term Disability Appeal - Need some FWF legal Help

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Backstory:
-DW had a forced early delivery @ ~6 months after her water broke randomly. Baby was born at around 26 weeks. As we all know, normal delivery time is about 40 weeks.
-Short term disability approved their standard 8-weeks @ 60% pay to cover the C-Section recovery.
-Baby has been in the NICU for the last ~90 days. She is finally getting to the point where she is about ready to come home. Keep in mind, mom's approved disability time was over at around 56 days. Since then she has been on FMLA leave and is about to run out of that.
-At this point, we have been appealing to the Short term disability insurance company that she is not yet able to return to work

Current Situation:
As it stands now, baby is finally looking to come out of the NICU within the next 2 weeks after being in there for so long. DW has definitely had her ups and downs - she was diagnosed with post partum and often has depressive times for obvious reasons. I really don't want to get into the details because I don't really have anything to prove to the audience as far as that goes. We saw a psychologist followed by a psychiatrist that had her formally diagnosed with it as well, and sent the information to extend the leave to the insurance company through the doctor's medical records.

Surprise surprise, insurance company doesn't want to cough up more money when people legitimately have issues. They denied the claim. Their response has about a couple sentences explaining why, with things like "there is no measureable [SIC] data provided to quantify impairment and no testing completed at the current time which would not indicate symptom severity". Uhhh, what? How do you give measurements for depression? Is there a depression machine that spits out a number of severity or something? Ridiculous.

So at this point, I feel like I'm between a rock and a hard place. Baby is about to come home in the next week or so. 

To top it off, DW's employer won't let her return to work (or use her paid time off/vacation hours) until she gets a letter from the doctor saying she is qualified to return. She has been going on for about a month now of unpaid leave - if we were to get a letter that said we are able to return to work, that would obviously work against us if we were trying to appeal for extension of disability. At the same time, because of this her employer won't allow her to take PTO, so we are stuck with no pay.


Open Questions

  • What should my action items be?  Currently on my list are:


  1. Gather all medical evidence - health records, mostly from psychiatrist. While I'm on the phone with the Doc ask what they reccomend
  2. Call Insurance Company - start the appeal process. I also plan to notify them that I will be filing a complaint against them
  3. File a Complaint with the state department of insurance

Anything else I'm missing? Is there any other legitimate sources I can file a complaint with? Does CFPB deal with insurance at all?

  • Whats my best course of action from the employer respective?

I feel a bit trapped here, because I can't get a letter from the doctor saying she was able to return to work, because that would work against me (and naturally it isn't true). At the same time, I feel it's rather ridiculous that I can't use her PTO hours in the mean time to maintain pay.

  • Baby will be home soon...

We are nearing the point in which the psychiatrist wrote in the documentation of her required time off period. How are we supposed to get her further tested for a time period that was in the past? Essentially they want more evidence, but I can't go back-in-time and get evidence for something that was in the past is what I am saying.

  • Would getting legal help be recommended? I do have Hyatt legal with my company, but obviously that doesn't pay for real legal costs of filing.



 

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Pick one - are you trying to get her back on the payroll at work, or are you trying to get her diagnosed with a psychiatric condition which prevents her from returning to work?  Post partum depression is real and debilitating, but not generally going to rise to the level of a disability.  It's not ridiculous that an insurer would deny a claim like this.  If her condition really is that serious, go back to her doctors and get them to sufficiently document it.  Having "ups and downs" isn't going to do it. 
 

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justignoredem said:   Surprise surprise, insurance company doesn't want to cough up more money when people legitimately have issues. They denied the claim. Their response has about a couple sentences explaining why, with things like "there is no measureable [SIC] data provided to quantify impairment and no testing completed at the current time which would not indicate symptom severity". Uhhh, what? How do you give measurements for depression? Is there a depression machine that spits out a number of severity or something? Ridiculous.
A quick G00gle search brought this up: Hamilton Depression Rating Scale (HAM-D) 
  A competent psychiatrist should be able to provide the necessary documentation/quantification to respond to the insurance company.
ETA: A better link listing more scales/screeners.

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dcwilbur said:   Pick one - are you trying to get her back on the payroll at work, or are you trying to get her diagnosed with a psychiatric condition which prevents her from returning to work?  Post partum depression is real and debilitating, but not generally going to rise to the level of a disability.  It's not ridiculous that an insurer would deny a claim like this.  If her condition really is that serious, go back to her doctors and get them to sufficiently document it.  Having "ups and downs" isn't going to do it. 
  
Myself (as the business-type) am trying to minimize losses. Simple as that. Don't confuse that with my wife and her diagnosis. Wife is diagnosed with a disability, and she has advised me that as such she wants to pursue the route.

The problem (as the business-type) is that I always do a risk assessment on anything I do in life. The risk here tells me that if said claims, appeals, etc... we're to be denied, we could be out of pay for multiple weeks/months. It's very apparent to me, that if the claims were to fall through (and we give up on appeals after exhausting all our options) then I would prefer to use her Paid time off at least to get our income.

There is no question in my mind that she would not be able to return to work, as her job requires on-the-spot cognitive function at all times. It's no desk job, that's for sure - and I don't want to get into it or feel like I have to defend myself.

So relating back to your last quote of " If her condition really is that serious, go back to her doctors and get them to sufficiently document it" - That's my problem, by the time she is able to get another appointment, the baby will be home, and her depression is likely to have subsided to a certain extent (or at the very least, not be as extreme). So how do I go to the doctor and say "diagnose me for how I was 4 weeks ago, I have a claim for that time period"?

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Every short term disability policy I have had ends at 6-8 weeks and then it jumps to the long term disability, and they are usually different. Is she covered by long term as well? Is that who you are appealing to?

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MilleniumBuc said:   Every short term disability policy I have had ends at 6-8 weeks and then it jumps to the long term disability, and they are usually different. Is she covered by long term as well? Is that who you are appealing to?
  
Short term disability is 12 weeks, long term kicks in at 13+ I believe (something to that nature). We are appealing to extend the short term from the standard C-Section recovery (8 weeks) to approx. the 12 week mark. 

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justignoredem said:   
MilleniumBuc said:   Every short term disability policy I have had ends at 6-8 weeks and then it jumps to the long term disability, and they are usually different. Is she covered by long term as well? Is that who you are appealing to?
  
Short term disability is 12 weeks, long term kicks in at 13+ I believe (something to that nature). We are appealing to extend the short term from the standard C-Section recovery (8 weeks) to approx. the 12 week mark. 

 I'm not sure I understand your appeal reason.  Is it based on C-section complication?  Or new diagnosis of postpartum depression? 
 

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Rubl said:   
justignoredem said:   
MilleniumBuc said:   Every short term disability policy I have had ends at 6-8 weeks and then it jumps to the long term disability, and they are usually different. Is she covered by long term as well? Is that who you are appealing to?
  
Short term disability is 12 weeks, long term kicks in at 13+ I believe (something to that nature). We are appealing to extend the short term from the standard C-Section recovery (8 weeks) to approx. the 12 week mark. 

 I'm not sure I understand your appeal reason.  Is it based on C-section complication?  Or new diagnosis of postpartum depression? 

  
It would be based on the new diagnosis of post partum. It goes without saying that the post partum likely has much to do with the fact that there were complications with the C-Section.

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justignoredem said:   Their (insurance company) response has about a couple sentences explaining why, with things like "there is no measureable [SIC] data provided to quantify impairment and no testing completed at the current time which would not indicate symptom severity". Uhhh, what? How do you give measurements for depression? Is there a depression machine that spits out a number of severity or something?
...
Wife is diagnosed with a disability, and she has advised me that as such she wants to pursue the route.

I think you are confusing 2 separate items: The first item is that your wife has been diagnosed with a condition, which I doubt the insurance company is questioning. The second item is, does that condition sufficiently impair your wife's abilities to meet the insurance company's definition of a disability. That is why the insurance company's response did not ask for proof of the condition, they asked for proof of how badly it impairs your wife. With any mental condition there is a wide spectrum of the impact on people, including with PPD where it can range from "poor sleep" to "trying to kill the baby".

Short term disability is 12 weeks, long term kicks in at 13+ I believe (something to that nature). We are appealing to extend the short term from the standard C-Section recovery (8 weeks) to approx. the 12 week mark. 
If the baby has been in the hospital for ~90 days, then it appears you should be looking into long-term disability right now as well. 
It would be based on the new diagnosis of post partum. It goes without saying that the post partum likely has much to do with the fact that there were complications with the C-Section.
Remember this: Nothing ever "goes without saying" for insurance companies. Say everything. In writing. Explicitly. Thrice. Keep copies and records

I feel a bit trapped here, because I can't get a letter from the doctor saying she was able to return to work, because that would work against me (and naturally it isn't true).
...
We are nearing the point in which the psychiatrist wrote in the documentation of her required time off period. 

I'm confused. On one hand you are saying the Doctor is saying she should now be able to return to work, but on the other hand you are saying she cannot return to work? If the latter, she's going to need a new review for time off in the future.  And getting a letter from a Dr that she is now able to return to work does not impact your short-term disability claim that fell within the prior time.
justignoredem said:   What should my action items be?  Currently on my list are:

  1. Gather all medical evidence - health records, mostly from psychiatrist. While I'm on the phone with the Doc ask what they reccomend
  2. Call Insurance Company - start the appeal process. I also plan to notify them that I will be filing a complaint against them
  3. File a Complaint with the state department of insurance



  1. Good start, but you are going to need to get the psychiatrist to provide what the insurance company asked for (quantification of impact).
  2. I would start this item before #1, or at least in conjunction with it. Get the company to provide specific detail of what they require
  3. Hold off on this until you have looked at 1/2.


And most importantly, I know this insurance stuff is stressful but make sure to not let it control everything and enjoy the time with your new addition, and congratulations

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Czechmeout said:   
justignoredem said:   Their (insurance company) response has about a couple sentences explaining why, with things like "there is no measureable [SIC] data provided to quantify impairment and no testing completed at the current time which would not indicate symptom severity". Uhhh, what? How do you give measurements for depression? Is there a depression machine that spits out a number of severity or something?
...
Wife is diagnosed with a disability, and she has advised me that as such she wants to pursue the route.

I think you are confusing 2 separate items: The first item is that your wife has been diagnosed with a condition, which I doubt the insurance company is questioning. The second item is, does that condition sufficiently impair your wife's abilities to meet the insurance company's definition of a disability. That is why the insurance company's response did not ask for proof of the condition, they asked for proof of how badly it impairs your wife. With any mental condition there is a wide spectrum of the impact on people, including with PPD where it can range from "poor sleep" to "trying to kill the baby".

Short term disability is 12 weeks, long term kicks in at 13+ I believe (something to that nature). We are appealing to extend the short term from the standard C-Section recovery (8 weeks) to approx. the 12 week mark. 
If the baby has been in the hospital for ~90 days, then it appears you should be looking into long-term disability right now as well. 
It would be based on the new diagnosis of post partum. It goes without saying that the post partum likely has much to do with the fact that there were complications with the C-Section.
Remember this: Nothing ever "goes without saying" for insurance companies. Say everything. In writing. Explicitly. Thrice. Keep copies and records

I feel a bit trapped here, because I can't get a letter from the doctor saying she was able to return to work, because that would work against me (and naturally it isn't true).
...
We are nearing the point in which the psychiatrist wrote in the documentation of her required time off period. 

I'm confused. On one hand you are saying the Doctor is saying she should now be able to return to work, but on the other hand you are saying she cannot return to work? If the latter, she's going to need a new review for time off in the future.  And getting a letter from a Dr that she is now able to return to work does not impact your short-term disability claim that fell within the prior time.
justignoredem said:   What should my action items be?  Currently on my list are:

  1. Gather all medical evidence - health records, mostly from psychiatrist. While I'm on the phone with the Doc ask what they reccomend
  2. Call Insurance Company - start the appeal process. I also plan to notify them that I will be filing a complaint against them
  3. File a Complaint with the state department of insurance



  1. Good start, but you are going to need to get the psychiatrist to provide what the insurance company asked for (quantification of impact).
  2. I would start this item before #1, or at least in conjunction with it. Get the company to provide specific detail of what they require
  3. Hold off on this until you have looked at 1/2.


And most importantly, I know this insurance stuff is stressful but make sure to not let it control everything and enjoy the time with your new addition, and congratulations

  
Thank you for the feedback. 

Yeah, sorry - my note on "returning to work" is confusing. Here is my complication - I want damage control. That means, if we aren't able to get approval (after all the fighting is said and done) then I would want to at least be able to have her company payroll back-date things so instead of having all this unpaid time off I would ATLEAST be able to put it as PTO and receive payment for that time. That's obviously something I desire to do less than getting the insurance approval. The problem is that in order for her to get back on company payroll my wife's employer wants a doctor signed letter saying she is able to return to work. Obviously, getting this letter wouldn't work if you're trying to argue against the insurance company.

My fear is simply through this long-drawn out argument with insurance we are going to have a lot of unpaid time off, at the very least if we have to give up I would prefer to be able to put in PTO over not getting paid at all.


As far as the rest of your advice, it sounds like we need to get another psychiatrist appointment ASAP to quickly do a test to quantify her disability? The problem is by the time we are able to get an appointment, the depression may have sub-sided since baby will be home. We all know how long it can take to get a simple doctor appointment.

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justignoredem said:   
The problem is that in order for her to get back on company payroll my wife's employer wants a doctor signed letter saying she is able to return to work.

  
Why? You shouldn't need a doctor's note to return to work after using FMLA to recover from a delivery. Did she tell them about the PPD and that she couldn't work because of that? If so, I think that was the big mistake here and that may be what is messing you up. Still, unless she has to do certain physical work, I find it hard to believe that the employer can not allow her to return to work. I would look into this requirement and find out whether they are actually able to do this. I wouldn't think that telling your employer about depression allows them to force you to take unpaid leave until you're "better."

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I understand your situation, but from the insurance company standpoint, PPD is going to be highly scrutinized. As emotional issues are not as easily recognizable as a broken leg, they are also easily taken advantage of. If they allowed STD for PPD, EVERY mother would try to claim a full a 12 weeks of disability as almost every mother experiences some PPD. Best of luck in your pursuit, but I imagine the STD route will be an uphill battle.

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justignoredem said:   Thank you for the feedback. 

Yeah, sorry - my note on "returning to work" is confusing. Here is my complication - I want damage control. That means, if we aren't able to get approval (after all the fighting is said and done) then I would want to at least be able to have her company payroll back-date things so instead of having all this unpaid time off I would ATLEAST be able to put it as PTO and receive payment for that time. That's obviously something I desire to do less than getting the insurance approval. The problem is that in order for her to get back on company payroll my wife's employer wants a doctor signed letter saying she is able to return to work. Obviously, getting this letter wouldn't work if you're trying to argue against the insurance company.

My fear is simply through this long-drawn out argument with insurance we are going to have a lot of unpaid time off, at the very least if we have to give up I would prefer to be able to put in PTO over not getting paid at all.


As far as the rest of your advice, it sounds like we need to get another psychiatrist appointment ASAP to quickly do a test to quantify her disability? The problem is by the time we are able to get an appointment, the depression may have sub-sided since baby will be home. We all know how long it can take to get a simple doctor appointment.

So if you can't prove that she has (or had) a short term disability, then you want to be able to prove that she could have returned to work? That's why I said you have to pick one; you can't have it both ways, and they really aren't mutually exclusive. I agree with the other poster who said that telling her employer about her depression diagnosis was a mistake. Now you have to dig out of that hole. Unless her depression is really severe, with a medical diagnosis to back it up, you probably aren't going to be successful with the insurance company. Focus on getting her cleared to return to work and then take the PTO for newborn care. Not questioning your motives, but from the outside looking in, the insurer and your employer have to just be thinking that you're just trying to get someone to pay her to stay home longer with the baby beyond what her own physical recuperation would have been.   

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meade18 said:   
justignoredem said:   
The problem is that in order for her to get back on company payroll my wife's employer wants a doctor signed letter saying she is able to return to work.

  
Why? You shouldn't need a doctor's note to return to work after using FMLA to recover from a delivery. Did she tell them about the PPD and that she couldn't work because of that? If so, I think that was the big mistake here and that may be what is messing you up. Still, unless she has to do certain physical work, I find it hard to believe that the employer can not allow her to return to work. I would look into this requirement and find out whether they are actually able to do this. I wouldn't think that telling your employer about depression doesn't allow them to force you to take unpaid leave until you're "better."

  
Precisely - that's exactly what I mean and I agree. I don't feel like we should have to get a doctors note saying you are able to return to work in order to use PTO time.  Also, as far as HR knows, the most I have told them is that we had a pre-term c-section delivery, and mom is in the NICU daily for bonding with the child...Which is true, for overall child development she has to at the NICU every day and is basically pumping 24/7 to feed the baby proper nutrition for best development. The most they know is that I am continuing to try to extend the claim with insurance, because as I said - they would otherwise require a return to work note from a doctor. So do you understand what I'm getting at? And how I'm kind of stuck in a limbo?

She doesn't have to do physical work, and it's actual much more of a mental job that requires 100% cognitive attention at all times (lives are essentially at stake - think mission control). PPD I would think would interfere even worse in this type of job that is more physical.

That said, thank you guys for the tips - in light of the denial from insurance it has definitely set things off much worse. This morning I scheduled an ASAP follow-up appointment with the psychiatrist and will plan to go in and accomplish all the requirements insurance is listing on their letter. It's absolutely ridiculous how many hoops we have to jump through given the already tumultuous stress levels and depression. I am also going to call the state department of insurance to get some advice on putting in a complaint. 

Still wondering if I am covering all my bases - or if there is any other options if these fall through.

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WTF is DW

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If her employer doesn't know that she's trying to claim PPD for extended disability, then get a doctor's note from the OB saying she is "physically" able to go back to work. As far as the employer knows, she was out of work for "physical" reasons and that's why they want a note. Getting a note like that shouldn't (hopefully) have a negative impact on any claims of "mental" issues.

IANAL (or doctor)

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king0fSpades said:   WTF is DW
  
DW = dear wife

 

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Just a wild guess but : the employer may want proof your wife is not disabled in order to keep people from double dipping on short term disability and PTO.
I'm guessing the STD is an employer provided benefit?

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jerosen said:   Just a wild guess but : the employer may want proof your wife is not disabled in order to keep people from double dipping on short term disability and PTO.
I'm guessing the STD is an employer provided benefit?

  
Employer (HR) specifically told me they have nothing to do with disability insurance, so any and all arguments on extending is with them. They just want me to update them on her anticipated return to work from what I understand. No idea where their stupid policy on not being able to utilize PTO while on leave comes from.

The Short term disability is through the employer (if that's what you mean by employer provided benefit). However, at the beginning of the year we were given the option to pay out of pocket for the coverage instead of the employer paying for it. Since we had a delivery (at the time, we expected it to be a normal delivery obviously) I opted to vote to pay for it ourselves out of pocket since the income through STD would be non-taxable income instead of taxable if the employer covered it.

 

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Something from my high-priced lawyer, Nolo Dot Com, Esq.

 Can Your Employer Demand a Fitness-for-Duty Certification?

Before reinstating you, your employer may require you to provide a written statement from your medical care provider, stating that you are medically able to return to work. Your employer can only demand this statement, called a “fitness-for-duty certification,” when the reason for your FMLA leave was your own serious medical condition. Your employer must also have a policy requiring such certification and must have followed it when other employees have taken and returned from medical leave.

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justignoredem said:   

  • Baby will be home soon...




 


Awesome
I suspect a huge uptick in overall mood

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pietromoon said:   
justignoredem said:   

  • Baby will be home soon...




 


Awesome
I suspect a huge uptick in overall mood

  
Exactly, which is why asking for a psychological test right NOW is absolutely ridiculous, considering there will be a massive change in mood, stress, and depression the moment the baby comes home. That is one of my biggest problems with this whole ordeal. How about anytime in the last 80 days of forced torture?

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I've had some experience with the OPs situation. It isn't as much a matter of what the diagnosis is in regards to whether a disability carrier will consider one disabled, but rather what is noted in the medical records of the medical provider which is given to the disability company. The medical provider must document how the condition is impacting the person's ability to function doing x, y, z. Just saying the person has post partum depression doesn't mean the person is disabled from doing their specific job. Either a psychologist or psychiatrist would be sufficient as they are both doctors (PhD vs MD).  Psychiatrist, one usually goes to for medicines for treatment, psychologist for non medicine based treatment.  If you haven't gotten copies of what has been provided to the disability carrier, I would get those first in order to see what the disability carrier is looking at to determine whether or not your wife is disabled from doing her specific job function. From what was written, it does not sound like the medical providers gave any support for her disability. If so, your anger shouldn't be at the disability carrier, but rather the doctors she was seeing. Lots of psychologist/psychiatrist don't support disability for mental illness unless they have been seeing the patient for extended periods of time (often 6 months or more). As far as I am aware, FMLA to take care of the baby and getting disability benefits are two completely separate issues.  If you are going for the disability, I really really don't think you want a doctor letter for the PTO route stating your wife can return to work as that would sink any disability claim.  I wouldn't assume how she will be once the baby comes home, but how she is right this second.

After seeing the medical evidence; perhaps you need a different medical opinion (which so far sounds to be the case) or if the medical opinion does in fact support the disability, lawyer might be good to help write the appeal. You really don't want it to get to the point that you need to file a lawsuit, because only the attorneys win at that point. If its an employer based disability policy, covered by ERISA, I imagine the cost will be prohibited with it having to be challenged in Federal Court and the time of disability only being a few months. Not an expert here, but my basic understanding is how you appeal it is very important as the policies often have very specific procedures for appealing denials. You don't appeal properly, you might sink your claim all together.

You wrote that it was an employer provided disability policy.  From my understanding ERISA covers employer provided disability policies so writing to the state department of insurance will just get told it needs to be handled in federal court.  CFPB will be the same result.  Curious, who is the insurance carrier/administrator?

Getting to see a psychiatrist or psychologist can take a while since mental illness was added to insurance policies via obamacare.  Disability carrier might accept the opinion from a licensed clinical social worker, which you probably could get one done immediately at a crisis center (assuming she really is having a crisis) or looking for one that is comfortable supporting a disability claim if they feel it is warranted base on their assessment. Have those medical notes sent to the disability carrier.

As I said, I have had some experience with this process and understand the OPs frustration.  Seeking legal advise I found wasn't what was needed, but rather the proper treatment plan by the proper medical providers. Perhaps doing a little research on your wife's diagnosis and when it generally is considered disabling could be useful.  This isn't legal advise as the OP title requested, but this is just my opinions from some firsthand experience in a similar matter.  

I wish the OP luck with getting this resolved in his favor and sympathize with dealing with this.

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justignoredem said:   
pietromoon said:   
justignoredem said:   

  • Baby will be home soon...




 


Awesome
I suspect a huge uptick in overall mood

  
Exactly, which is why asking for a psychological test right NOW is absolutely ridiculous, considering there will be a massive change in mood, stress, and depression the moment the baby comes home. That is one of my biggest problems with this whole ordeal. How about anytime in the last 80 days of forced torture?

  Are you saying right now your wife is in good spirits and asking for a psychological exam would be a waste of time since she was depressed before, but not anymore?  So not disabled anymore, but she was anytime in the past 80 days?  Then I would say the medical providers either did your wife a disservice by not properly evaluating, documenting or they just felt she didn't meet their criteria of being disabled.  Get the medical notes/documentation they provided the disability carrier. My bet is that the claim is being denied due to the medical providers, NOT the insurance company not wanting to pay out.  That's just my hunch from what you have written.

Having the right medical providers, with the right diagnosis (severity), with the right treatment plan is most important with disability when it isn't a clear cut situation like Schizophrenia, laid up in a full body cast, Parkinson's Disease, etc.

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justignoredem said:    As we all know, normal delivery time is about 40 weeks.
 

  I always thought it was 9 months, no?

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atikovi said:   
justignoredem said:    As we all know, normal delivery time is about 40 weeks.
  I always thought it was 9 months, no?

  38-40 weeks is term delivery.

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So what's the differance between normal and term delivery?

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Full term delivery = normal delivery

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jcohen73 said:   I've had some experience with the OPs situation. It isn't as much a matter of what the diagnosis is in regards to whether a disability carrier will consider one disabled, but rather what is noted in the medical records of the medical provider which is given to the disability company. The medical provider must document how the condition is impacting the person's ability to function doing x, y, z. Just saying the person has post partum depression doesn't mean the person is disabled from doing their specific job. Either a psychologist or psychiatrist would be sufficient as they are both doctors (PhD vs MD).  Psychiatrist, one usually goes to for medicines for treatment, psychologist for non medicine based treatment.  If you haven't gotten copies of what has been provided to the disability carrier, I would get those first in order to see what the disability carrier is looking at to determine whether or not your wife is disabled from doing her specific job function. From what was written, it does not sound like the medical providers gave any support for her disability. If so, your anger shouldn't be at the disability carrier, but rather the doctors she was seeing. Lots of psychologist/psychiatrist don't support disability for mental illness unless they have been seeing the patient for extended periods of time (often 6 months or more). As far as I am aware, FMLA to take care of the baby and getting disability benefits are two completely separate issues.  If you are going for the disability, I really really don't think you want a doctor letter for the PTO route stating your wife can return to work as that would sink any disability claim.  I wouldn't assume how she will be once the baby comes home, but how she is right this second.

After seeing the medical evidence; perhaps you need a different medical opinion (which so far sounds to be the case) or if the medical opinion does in fact support the disability, lawyer might be good to help write the appeal. You really don't want it to get to the point that you need to file a lawsuit, because only the attorneys win at that point. If its an employer based disability policy, covered by ERISA, I imagine the cost will be prohibited with it having to be challenged in Federal Court and the time of disability only being a few months. Not an expert here, but my basic understanding is how you appeal it is very important as the policies often have very specific procedures for appealing denials. You don't appeal properly, you might sink your claim all together.

You wrote that it was an employer provided disability policy.  From my understanding ERISA covers employer provided disability policies so writing to the state department of insurance will just get told it needs to be handled in federal court.  CFPB will be the same result.  Curious, who is the insurance carrier/administrator?

Getting to see a psychiatrist or psychologist can take a while since mental illness was added to insurance policies via obamacare.  Disability carrier might accept the opinion from a licensed clinical social worker, which you probably could get one done immediately at a crisis center (assuming she really is having a crisis) or looking for one that is comfortable supporting a disability claim if they feel it is warranted base on their assessment. Have those medical notes sent to the disability carrier.

As I said, I have had some experience with this process and understand the OPs frustration.  Seeking legal advise I found wasn't what was needed, but rather the proper treatment plan by the proper medical providers. Perhaps doing a little research on your wife's diagnosis and when it generally is considered disabling could be useful.  This isn't legal advise as the OP title requested, but this is just my opinions from some firsthand experience in a similar matter.  

I wish the OP luck with getting this resolved in his favor and sympathize with dealing with this.

  
Thanks for your advice on this issue, I can tell you definitely know what you are talking about here - because this is what I have slowly learned as well. The problem with this line of reasoning, is that my wife and "doing her job" isn't the issue. It shouldn't even be the topic of conversation. The topic is in regards to her child, so it makes sense that her employment, job duties and such didn't come up in her first appointment. They shouldn't be able to deny a claim simply because the topic of conversation isn't a job.

Can you explain your point on ERISA more? Are you basically saying anything that is an employer provided insurance will never have to go through any scrutiny at the state level? And there is no way to fight it at the federal level outside of a lawsuit?

Also since you asked (didn't realize I haven't mentioned this yet) the insurance company is CIGNA.

Update: 

  • Bit the bullet, decided to fight this out with disability insurance, wife has since returned to work on 7/11 - as specified by the psychiatrist. Now it's just a fight between me and the insurance for the retroactive dates over the last month that I'm trying to get payment for.
  • Cigna denied our original claim for extending the disability. The issue with the first claim for extending is that the psychiatrist didn't fill out everything in the paperwork, mostly because she didn't feel qualified to answer it. Many of them were specific to her job, and unless she knew and discussed what her job was she didn't know how best to answer them (which let's be honest, that wasn't the priority discussion - which was the child).
  • I have since written an appeal letter (didn't seek legal advice due to lack of time, but I probably should have), we had multiple follow-ups with a psychiatrist and multiple psychologist appointments and she is pretty adamant in her latest writing that she should not be working at her job. She also started a treatment plan with medication. Only issue I saw in the latest paperwork is she said specifically as of her latest appointment - which I'm hoping the insurance doesn't try to use this wording to say they will only cover after the dates in which you were formally diagnosed. Obviously the date you were diagnosed has nothing to do with the date in which it started. 
  • We tried contacting her employer's HR, to see if they would vouch for if an employee has x, y, and z symptoms (which Cigna acknowledged in their denial), would you allow that person to work knowing lives are at risk. The HR declined, likely because of contractual obligations with the insurance I would suspect.
  • Waiting on Cigna's reply at the moment, they said it can take up to 2 weeks.


Really hoping this resolves everything and approves it. It's overall a minuscule amount for them, and after this appeal I'm not sure of any other ways to proceed other than complaining to the Insurance department of Texas. Any other tips or ideas if I need to fight on would be appreciated.
 

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This link will explain the ERISA issue better than I can. http://www.nolo.com/legal-encyclopedia/differences-between-erisa... 

I'm not sure I even understand your comment "The problem with this line of reasoning, is that my wife and "doing her job" isn't the issue. It shouldn't even be the topic of conversation." Perhaps you can clarify how/why you say this? Disability policy general covers one's own ability to perform either their job or any job depending on the disability policy. I'm under the impression that generally disability policies do not cover taking care of a family member or child. FMLA provides protection in order to take care of a child or family member, but that is separate from getting money from a disability policy.

Whether you agree with it or not, a child being in the hospital doesn't prevent a parent from working unless it's causing some issue like depression that IS preventing her from doing her job and performing the functions of that job. And yes, if she isn't discussing with her medical providers how HER issues is impacting her from doing her job, then they can't assume it is. Again I know it sounds clear to you that your wife's diagnosis is preventing her from doing her job, but unless she spells it out to the medical providers, it isn't preventing her from doing her job.  The medical providers do not need a detail understanding of her job to document whether her issues is causing her to be unable to perform her job.

I'm also a little confused that you got medical providers adamant that she shouldn't be doing her job, yet she returned to work on 7/11. That sounds like she isn't following medical advise which the insurance company alone may use that to deny her claim.

Personally, if you want to pursue this I think it is best to get legal advise as this is beyond opinions at this point and you need someone who really understands this stuff thoroughly.

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jcohen73 said:   This link will explain the ERISA issue better than I can. http://www.nolo.com/legal-encyclopedia/differences-between-erisa... 

I'm not sure I even understand your comment "The problem with this line of reasoning, is that my wife and "doing her job" isn't the issue. It shouldn't even be the topic of conversation." Disability policy general covers one's own ability to perform either their job or any job depending on the disability policy. I'm under the impression that generally disability policies do not cover taking care of a family member or child. FMLA provides protection in order to take care of a child or family member, but that is separate from getting money from a disability policy.

Whether you agree with it or not, a child being in the hospital doesn't prevent a parent from working unless it's causing some issue like depression that IS preventing her from doing her job and performing the functions of that job. And yes, if she isn't discussing with her medical providers how HER issues is impacting her from doing her job, then they can't assume it is. Again I know it sounds clear to you that your wife's diagnosis is preventing her from doing her job, but unless she spells it out to the medical providers, it isn't preventing her from doing her job.  The medical providers do not need a detail understanding of her job to document whether her issues is causing her to be unable to perform her job.

I'm also a little confused that you got medical providers adamant that she shouldn't be doing her job, yet she returned to work on 7/11. That sounds like she isn't following medical advise which the insurance company alone may use that to deny her claim.

Personally, if you want to pursue this I think it is best to get legal advise as this is beyond opinions at this point and you need someone who really understands this stuff thoroughly.

  
Yes, but my point is that being disabled from her job is an indirect affect of the issue. When you go to a doctor the point of it is to diagnose your issue (cause/affects) and to to address the issues with a plan of treatment.

So in our case, what's the issue? Your baby was born extremely prematurely, and it has burdened you with stress, and you are having depressing thoughts and a large line of symptoms that the doctor listed. Okay, so what's the solution? Try to find ways to relieve stress and not have depressing thoughts via treatment. At what point during that discussion does the question of job expectations come up? It doesn't, is my point. Which is why it wasn't asked in the first appointment. The doctors concern was with the issues, not her job. Yes, the doctor diagnosed her symptoms, but she didn't feel qualified to discuss the job because the job wasn't the topic of conversation. Does that make sense? that's why on the initial paperwork for questions concern her job she wrote the equivalent of "N/A - Did not formally discuss" or "No opinion". This would seem apparent to me that in order for the medical provider to answer those questions, she needed to discuss her job in more detail. And let's be honest here - depression can affect you differently depending on your job. A blue collar job is very different than a white collar job, and a retail job is certainly different as well. Each one requires different skill sets, some are more physical, some are more mental.

The doctor was adamant about not returning to work based on her 2nd time filing out her paperwork and from further appointments with her (and psychologists that report to her) - it was in these LATER appointments that they actually had the time to discuss her job and expectations for her job to formally answer those questions. She returned to work on 7/11 based on the original treatment plan that she outlined from day 1, so if anything it lines up perfectly with the assessment and treatment plan.

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