LTD insurer approved claim but only for 6 weeks??

[MissStress]

I was diagnosed with Major Depressive Disorder in June after being off work for 6 months with medical issues, I was suicidal and had tonnes of crap going on in my personal life. I am still waiting to get fully diagnosed and I have other medical problems (like a tumor in my head for starters, they just don't know what kind of tumor yet) and a 6cm cystic lesion on my left ovary (plus much much more).

My GP recommended I apply with MDD as the main medical issue as the insurance company would say 'people who are depressed can't work' - 'people with tumors can'.

Sun Life is my union's LTD provider, they said they will approve me for only 6 weeks, my doctor's report said I still need another 4 to 6 months and am still dealing with other medical issues which are exacerbating my condition. I still haven't been able to get in to see a psychiatrist, I live in Northern Canada and it takes 4 months or more from referral until one can get an appointment with a psychiatrist.

I asked my 'case manager' at Sun Life what are my options when I finally get diagnosed and she wouldn't discuss it with my until reviewing my file... again. said she would get back to me on Monday (it's Friday) not holding my breath.

As of Monday it will be 10 weeks since I applied for LTD benefits, they state it takes 8-10 weeks to be approved and near the end of June, my case manager said she could only keep my application open for 6 more weeks. Am I being screwed and on Monday they're going to say.. oh sorry.. time has expired?

We're really suffering financially, are selling assets, may lose our home. I was/have made progress but this has thrown me back in to the black hole of despair.

Suggestions on where to go from here? I have a call out to my union business manager but they haven't been able to help people in my situation in the past, waiting for a call back.

 

[Retired]

I asked my 'case manager' at Sun Life what are my options when I finally get diagnosed and she wouldn't discuss it with my until reviewing my file.. again.. said she would get back to me on Monday (it's Friday)

In situations such as this where bureaucracy seems to be the obstacle, it often helps to work your way up the management chain, with perseverance.

If they haven't called you back in the time promised, you should be following up.

There's no point dealing with a person who only has the authority to say "no", so you need to identify the person who can say "yes". In a corporate bureaucracy, first ask to speak to the immediate supervisor of the person to whom you are speaking.

The key to doing this successfully begins as soon as the call is answered. Ask the full name of the person to whom you are speaking. If they cannot give you their full name (often happens at call centers) then ask for their location (City, branch etc) and for their extension number The only reason you need to give is that you are maintaining a file and need to identify whom you're speaking to. Having this information usually ensures the representative will deal with you more diligently.

If the answers you need are unsatisfactory, ask that they transfer you to their supervisor. This should be done without being aggressive, but on the basis, "if you don't have the authority to approve this, then I want to speak to the person who has".

Same process..get the full name of the person your talking to ....and continue working your way up the ladder.

Keep careful records of your conversations, retaining the names and contact information of those to whom you have spoken. This evidence will be valuable in the event of an appeal.

Find out if the Company has an Ombudsman who can hear your appeal.

Sometimes insurance companies will want you to be seen by one of their own medical consultants, so if they ask you to do this, comply with their request. It's a normal part of the process.

Enlist the help of your doctor(s) if possible to provide letter of support that you can mail to the company, retaining copies for your files.

Bottom line: you need to be your own strongest advocate in dealing with the insurance company, as difficult as it may seem. The people in call centers are sometimes poorly trained, don't fully understand what you are trying to tell them and will often just refuse your request, because that will get you off the line.

If you are not up to the verbal skirmishes, perhaps a trusted friend or family member can do the talking with you in the room to assist with necessary information.

 

[MissStress]

Thanks for the reply Steve,

This wasn't someone in a call centre, this was my case manager whom I have been dealing with over the last 10 weeks. I have her direct line, full name. She has never.. not once.. called me back when she said she would and has had all the medical information they requested (my entire 275 pg medical file, a report from my psychologist, copy of my BDI, my DSM IV 'label'.) for a over a month but still has to review it.. again.. after their doctor just did.. before discussing medical particulars with me?

Not sure if escalation is the route to go at this point, she's already said I am approved, but only for 6 weeks.. which means after 10 weeks of waiting, I get $3500 and a "so sorry but you're better so no more support for you" line.. I'll check to see if there's a Sun Life Ombudsmen, not fricken holding my breath though. Appeal is a possibility guess.

Have a call out to these folks, hoping they can help me file complaint against Sun Life (Can't post links yet) Office of the Superintendent of Insurance which comes under the Consumer and Protective Services Branch and is supposed to investigate complaints against insurance companies.
Still waiting to hear from my union business manager, considering legal options.

 

[Retired]

file complaint against Sun Life (Can't post links yet) Office of the Superintendent of Insurance

I cannot see that you would have much success following that strategy because it seems your issue is one of policy interpretation, which should be handled internally within the company.

If the case worker did not reply, have you determined if this person was on vacation or was not returning your calls? In any case, I believe your best recourse would be to work your way up the management chain.

Of course, as you are aware, these situations are best resolved when cooler heads prevail, using facts presented in a polite yet assertve manner. If the person you're talking to is trying to help, give them the opportunity to help; but if it becomes evident they have reached the limits of their authority, then it's time to move up the management ladder.

You want to communicate with someone who can say "yes" within the Sun Life; going outside the Sun life at this point is not likely to give you that.

considering legal options

Again, entering into an adversarial position can be costly and may not produce the results you want. Locating the person at the Sun life with authority, in my opinion, is your best strategy.

 

[MissStress]

You're absolutely right Steve. I was still dealing with the shock and anger... thanks for bringing me back down to earth (somewhat )..

 

[Daniel E.]

I don't know much about this stuff, but some info by someone on LTD:

• You should read over your policy completely and find out if there are limits to your LTD, e.g. if they require a specific specialist for the LTD or if a family doctor is acceptable.
• It is possible they may give you short term disability benefits to start. Some policies begin with a short term disability or sick leave and then turn into LTD.
• If you are eligible, apply for EI (Employment Insurance Benefits) in the meantime. They offer 15 weeks payment. Many insurance companies require that this be exhausted before they will approve the claim.
• The best thing you can do is read your policy very closely and make sure your insurance company is following the policy. Do not let them bully you or push you around. If your doctor is in total agreement with you, your doctor will know how to deal with them. Have the insurance company direct any medical inquiries to your doctor.

 

[MissStress]

Thanks Daniel,

I did collect STD for 6 months through our company plan but LTD is provided by a different company through the union.
That being said, they told me one thing on one day and a different story the next. Things don't seem so dire now.
They will cover the last six weeks plus up to an additional 4-6 weeks. Want to start a back to work program with my doctor and want to see me back at work full time by mid-Nov. I haven't even had my initial appointment and evaluation with my psychiatrist since being referred 4 months ago so not sure how they expect that to happen. Time will tell I suppose.
Still waiting for the porphyria test results to come back as well.. Still so many "what if's" and "could be's" and I am still having many physical symptoms (pain - wide spread, chronic, acute and bone), nausea, photo sensitivity, still have a parotid tumor of an unknown variety, waiting for biopsy #3, hypertension that comes and goes (from 117/74 to 160/100?) .
Will keep you all posted.