Note: personal client details have been changed. The claim details and name of the insurance company have not.
Client: Tracy B.
Job: Help Desk Tech (sedentary, requires uninterrupted phone calls and keyboarding to log service issues for clients who call in)
Disability: MS, IBS and Psoriatic Arthritis (hands)
Policy: STD and LTD
Insurance Company: Matrix/Reliance Standard
IAC Services: Free Denial Letter Review, Disability Appeal Planning Session, Appeal Coaching
Tracy’s Short Term Disability (STD) claim was denied with a few weeks to go before it would have transitioned to Long Term Disability (LTD). Although she had already filled out and returned her LTD application forms, her STD claim manager told her that since her STD claim was denied, she was not eligible for LTD. (That’s rarely true, but Tracy didn’t know that).
Tracy contacted an attorney who referred her to us, based on the limited medical treatment she had so far (visits with her Primary Care Provider only, though her PCP fully supported her claim) and her benefit amount ($3,000/month before offset for SSDI benefits). Providing full contingent-fee representation (“only pay if we win”) just was not possible for this case. We were happy to step in.
After reading our Free Denial Letter Review, Tracy hired IAC for a Disability Appeal Planning Session to map out specific next steps for the appeal. She sent us her recent medical records and the additional correspondence she had with Matrix about her STD claim. We met over video chat for about an hour to fully discuss the context for her claim, which was slowly worsening MS, IBS and arthritis symptoms that had first restricted and then prevented her from working in her sedentary job.
After the Planning Session, we gave Tracy a draft appeal letter for Matrix, guidance letters for her doctor and colleagues about how they could support the appeal, and a clear “Next Steps” report that gave her a roadmap for finishing the STD appeal, asking for a decision on her LTD claim, and dealing with whatever came next from Matrix.
As she worked on her appeal plan, Tracy was uncertain about whether and how to include new medical records in her STD appeal. She decided to hire IAC again for Comprehensive Appeal Coaching. We discussed how Tracy could talk with her PCP about referrals to specialists who could then document the extent of her impairments. Tracy went to see a Rheumatologist, Gastroenterologist and Neurologist for updated testing and treatment plans. We gave her additional guidance letters to share with her doctors about how they could help with the appeal. We added the pertinent new medical records to the appeal package as they came in, and edited the appeal letter to reflect the new test and exam results. And of course, we highlighted in the STD appeal letter that the STD claim manager was wrong, and Tracy remained eligible for LTD. Even though this was “just” an appeal for a few weeks of STD benefits, we treated it as a chance to get her LTD claim approved and paid to date without having to go through another appeal.
Tracy submitted her STD appeal and heard back within a few days that she won the appeal! Matrix changed their claim decision and approved her STD claim to the maximum end date. The LTD decision took a few weeks longer, but she got good news there as well – her LTD claim was approved, and her check for about 6 months of LTD back benefits was in the mail.
Takeaway #1: the insurance company is often blatantly wrong – not just about whether you’re disabled, but what benefits you’re eligible for. Don’t abandon an LTD claim just because someone told you over the phone that you’re not eligible. Tell the insurance company to put that in writing. They’ll either back down, or give you an actual denial letter that will normally have appeal rights.
Takeaway #2: support from your PCP alone is often enough to get an STD claim approved, but that’s it. The insurance company is impatient. They want to see that you’re either getting better or that you’re pursuing additional treatment. For all but the most obvious conditions, they won’t accept that you are at “maximum medical improvement” without a paper trail of specialist visits, medical records and test and/or exam results that document the extent of your functional impairment.
Do you have a denial letter from an insurance company and aren’t sure what steps to take next? Let us help. We’ll review your denial letter for free and give you a written report about what steps we think you’ll need to take next to appeal. If you want more help, we’re here, but there’s no obligation to get that initial report. Get started at Free Denial Letter Review.
