Long term private disability insurance denial

Status
Not open for further replies.

JRK210

New Member
My jurisdiction is: California

I am a 51 yr old physician and have been unable to work for the past 4 years due to a bulging lumbar disc causing back pain and left leg sciatica to the point of being unable to stand/walk more than 5 minutes. It is not due to an injury, but slow degeneration of the spine, and thus also, no specific day of sudden onset. I’ve been paying on a group long term disability insurance policy through the AMA, underwritten by New York Life, which in turn is under the umbrella of and administered by AIG. I’ve had 4 years of physical therapy, chiropracty, corticosteroid treatments, epidural spine injections, surgery, acupuncture and more. Determined to recover at some point, I never considered applying for long term disability until Aug 08. Although being told that I would be informed of a decision in 30 days, AIG took 5 months to finally send me a letter denying me benefits. Their denial was based on 2 factors. First that we were unable to obtain any medical records, and therefore verify my treatments from 2004-2006 by a physician who passed away and his records subsequently destroyed by the family. Secondly, they then claim that this 2 year gap then disqualified me from their definition of “actively at work”, and therefore unable to pay. This definition includes persons that, although not actively going to work everyday, they are temporarily away from work due to other reasons, but they intend to return to working at the same job, and are not retired. The policy is job specific, and to this day, I cannot stand more than few minutes without debilitating pain, making me unable to work at my normal job in clinical medicine. Meanwhile, their delay and now added delay in appealing the decision has set me back further with obtaining further care/surgery due to financial concerns. My questions regarding appeal include: shall I pursue it myself or seek an attorney to do so? should I write to request a copy of AIG’s records used in determining my case, or have attorney? And finally, when submitting an appeal, I understand that the case has to be re-evaluated by persons that were not involved in the initial evaluation/determination. My concern is that, in appealing to the 2 specific reasons for the initial denial, is a completely new (team of) persons then evaluating the case answering to only the 2 factors of concern, or are they allowed to, by completely re-evaluating the case from the beginning, able to now come back with other reasons for denying benefits, in the case that the arguments I submit in my appeal are determined to be in my favor? Thankyou.
 
Status
Not open for further replies.
Back
Top