Denial of benefits/coverage and [View all]

[moniss]

slow-walking payments has been with us previously but not to the massive high tech manner it is today. One of the strategies employed by insurance companies is to deny coverage for procedures for serious conditions hoping you will die and then they have "saved" all that money. If you appeal they may drag out the appeal decision endlessly while they ask for more documents and then more and more all the while you are hoping you're getting somewhere. Meanwhile the bottom line financial results reported to Wall Street look great because less is being paid out due to the strategy of "you can't make us pay and we hope you die trying".

I have little doubt that a somewhat similar strategy of "you can't make us" is coming for those receiving SSI Disability benefits. I expect the incoming circus of ghouls is going to invoke a strategy of taking a large percentage of those receiving benefits and making them "requalify". They may suspend benefit payments during the "requalify" period but I can assure you that the process, by their design, will not be quick in restarting your benefits. Private insurance carriers have employed strategies like this regarding disability insurance benefits/claims.

I know personally of two people who encountered these scenarios. One of delay and the other of requalify.

The first was a Work Comp case. A young man badly injured a knee while performing duties at his job. It required major reconstructive surgery and at that time the recovery period was very long. The insurance company providing the Work Comp policy to the employer denied the claim. They simply said they had determined the injury wasn't work related. As absurd as that sounds it was not uncommon for companies to do this. The man then had the right to request the company to reconsider. They had 90 days to do so. On the 89th day they dated and postmarked an affirmation of their denial. The young man now had a right to ask for a State administrative review since Work Comp is also state regulated. So the young man filed for his hearing. About 2 weeks later he received a letter from the State indicating that his hearing was scheduled for 18 months in the future. The huge backlog of cases due to insurance company denials was overwhelming the personnel at the State level.

So as hearing day finally approached the young man was hopeful that finally this absurdity could be corrected. It was placing great strain on his young marriage and the lack of ability to work was a huge problem. No unemployment check because that Agency said that it didn't qualify due to "voluntary" separation from the job. A whole other story. But hearing day was coming and hope springs eternal. Until the letter from the State arrived 3 days before indicating that the insurance company had requested a delay in order to obtain further evidence. They were granted the delay and the new hearing was now to be another 12 months into the future. During the 12 months the only "further evidence" the insurance company gathered was sending out an extensive form for the young man to fill out. Several pages about his condition etc. So the first hearing date is held and the insurance company lawyer listens to the doctor for the young man testify and then makes a request for an adjournment and rescheduling so they could "obtain further medical testimony". The State granted the delay but "fast-tracked" the new hearing to now be held in 6 months. The young man was sent to see the insurance company doctor. Years after the first notice of claim.

So the new hearing date came and the lawyers for both sides began and the insurance company lawyer tried to have a person from the employer sworn in to give testimony. The attorney for the young man was a very astute lawyer and he immediately objected and reminded the Administrative appeals panel, consisting of 3 people, that the delay had been granted for "medical" testimony and unless the proposed witness was qualified to speak on medical matters in the case then allowing him as a witness was out of order. The panel agreed. The insurance company doctor was not present and so his report was inadmissible since no cross-examination of a document is possible without the person who wrote the document being present for questioning. So the panel adjourned and said they would forward a decision.

Almost 6 months later the young man received the good news from the State that they had granted his claim. It gave the insurance company 90 days to file an appeal. On the 89th day they dated and postmarked a check to the young man.

So basically 3.5 years went by with no work, the financial strain sent the young man into a spiral and the marriage to the rocks. The size of the check for his wages was just over $11,000.00. The medical bills were modest compared to today. They ripped a human being apart and took over 3 years doing it all over $11,000.00 and about that in medical bills. The rate of increased divorce goes off the scale for medical and disability cases. They know the damage they do. For $11,000.

The second case is more brief in the telling but no less sad. A young woman who had a disability insurance policy developed a debilitating connective tissue disease that rendered her totally disabled. The name of which she told me but it is so long and complex that at least a half dozen letters of the alphabet went on strike for being overworked. Initially for the first few years things went well and her very expensive medications etc. seemed to stabilize her. But "new kids on the block" at the insurance company decided that people receiving long term benefits were likely to be "malingering" and so they began a blanket program of suspending benefits and requiring "requalifying". So this condition the woman had gave her periods of good times when she was stable enough to leave the house for a doctor appointment and bad times when she would be in very bad shape. She had a full day caregiver. Because the "new kids" demanded she show up for appointments on their schedule rather than during her stable times it began to negatively affect the progression of her condition. Despite restarting her benefits the medical condition had now deteriorated and she died several months later.

The insurance companies do these things because they can and because they want to put more money in their pockets. The incoming circus of ghouls for Donald Crumb loves stories like this and it gives them a thrill and a smile to be able to inflict similar damage to people and their lives.