issues with short term disability insurance

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issues with short term disability insurance

Post by wahnfried » Mon Oct 07, 2019 7:23 pm

dear fellow bogleheads,
i'd like to hear your thoughts about my problem:
my medical group( my employer) changed the STD insurance company as of 1/1/2019.
i became disabled as of 9/1/2019 ,and will be for probably for 3 months.
when i applied for STD benefits i was told that there is a clause that absolves the insurance from paying if there are preexisting conditions with in the 12 months preceding the file of my claim. there are no preexisting conditions .
long story short , they demand to know everything about my medical history over the last year, request hospital records, PCP statements etc etc.
of course not everybody responds right away and the whole saga drags on. meanwhile i am 7 weeks out of work and no payment has been made ,
of course there is always another statement they want about hospitals, doctors or pharmacies.... basically they delaying and dragging their feet

here are my questions:
do STD insurances have the right to demand private medical information ( HIPPAA anyone ?)
can i take them to court for breach of contract?
is there a national / state ( i'm in NM) review board that i can use to file a complaint ?
any other ideas what I can do ? i am getting really upset.
thank you for your thoughts !

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Re: issues with short term disability insurance

Post by 123 » Mon Oct 07, 2019 10:03 pm

They would seem to need private medical information if they have to decide if you are or have been disabled as defined by the policy.
They would seem to need medical records for the 12 months prior to the date of your claim to establish that the current claim is not the result of a pre-existing condition within the 12 months preceding the filing date of your claim.

Most states have a State Insurance Commissioner that regulates the activities of insurance companies within the state.
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Re: issues with short term disability insurance

Post by LookinAround » Mon Oct 07, 2019 10:24 pm

I would think they have a right to ask questions about your medical history, records, etc. However, they don't have a right to drag their feet and bury you in paperwork to avoid a claim - if that's what you think they're doing.

1) just from googling i believe you can complain to New Mexico Office of Superintendent of Insurance

2) Some local TV stations have segments where they look into consumer issues/complaints and get results by publicising the business name. If any local stations do so? Try contacting them as well

Good luck!

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Re: issues with short term disability insurance

Post by Stinky » Tue Oct 08, 2019 7:03 am

Have you talked to your employers’ Human Resources department or person about your delays?

It can’t hurt, and it might help.

I do believe that the insurer has the right to investigate your claim before paying it.
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Re: issues with short term disability insurance

Post by ResearchMed » Tue Oct 08, 2019 7:18 am

You would probably benefit from contacting the state insurance commissioner's office. It appears that someone posted a link to that above.
The insurer should not be dragging their feet, but you may want to contact all of your providers' offices to make sure they did get the request for paperwork and they are indeed processing things promptly.

Also, about HIPAA... I would assume that in filing your claim you gave permission for the insurer to get information from your medical records. Otherwise, however could they determine if you are disabled or not? They do have the right to determine if claims are valid.

As for the past 12 months, are you sure that is in the contract? Or might there be a 12 month waiting period from the start of employment? Are you a recent hire at your company?
If this is due to the change in policy by your employer, again, I'd check with the insurance commissioner's office about whether the new provider can "behave" as though this were an entirely new coverage for individuals.
This bit about no "pre-existing conditions" for a disability claim doesn't quite make sense. Unless there is some accident or a "sudden onset" illness, many people who need disability coverage need it because some medical problem has become worse and they can no longer work. Did the old policy have that same restriction? It just seems odd, if it is for more than the initial time after a new hire (perhaps to prevent someone from taking a job while ill, just to get the disability benefits?).

Good luck, but do be pro-active with your medical providers about getting those forms filed, IF that is part of the delay.

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Re: issues with short term disability insurance

Post by delamer » Tue Oct 08, 2019 10:56 am

I’d be very surprised if your application for benefits didn’t include a clause allowing then to request your medical records.

You wouldn’t expect them to take you at your word that you can’t work, would you?

Have you confirmed with your providers that they have sent the insurer the requested records?

I hope you have a speedy recovery.

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Re: issues with short term disability insurance

Post by Artful Dodger » Wed Oct 09, 2019 2:01 pm

I'll concur with what Research Med said above. Your 12 months starts at the time you became employed / went on the STD plan. It shouldn't matter if your employer switched companies. The new carrier will accept the employees already on the plan and either waive their pre-ex wait, or give them credit for the actual time already enrolled on the plan.

When you went on claim, your employer would have submitted a claim on your behalf to the carrier. It requires a statement from them, from you as the claimant, and a report from your doctor describing the medical condition / reason for disability. The company will often reach out to your doctor for more information, and may request other records to substantiate your claim. That's the way it works.

Usually STD, as opposed to LTD (long term) is a simple process and approved quickly. If, you have issues, you can reach out to your employer for help, or call the claims department directly to see what the hold up is. Sometimes providers don't respond, sometimes records go astray, sometimes you need to clarify / address concerns. If they actually deny the claim, and your employer is of no help, you can usually appeal to your state's department of insurance. If they are of no help, you can get an attorney. They will be able to advise you whether a court action is warranted.

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Re: issues with short term disability insurance

Post by wahnfried » Mon Oct 14, 2019 6:11 am

Dear friends ,
Thank you so much for your replies !
I am grateful for your help and thoughtfulness,
While I am still stuck with this so called insurance ( reliance standard life insurance in Philadelphia, be warned ! )
I feel better already and will proceed with reporting them to the review board .
Appreciative ,

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Re: issues with short term disability insurance

Post by djpeteski » Mon Oct 14, 2019 6:25 am

STD =? Standard or something very different.

My wife is in OB and my mind always goes there after her work stories.

OB == obstetrics

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Re: issues with short term disability insurance

Post by ivk5 » Mon Oct 14, 2019 6:47 am

djpeteski wrote:
Mon Oct 14, 2019 6:25 am
STD =? Standard or something very different.
The thread title eliminates any reasonable ambiguity.

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