STUCK IN A DISABILITY VS. DOCTOR CONUNDRUM

Mama Cass

OK, so I have posted before how very little Kaiser has done for diagnosis and even less for any kind of treatment.

Now the lack of effort put into diagnosis is coming back to haunt us.  
Long term disability wants to see "biological" evidence of cause of dementia, otherwise they are treating my DH's diagnosis as a mental illness and will drop him after 1 year..  My DH's doctor says he will consult with a neurologist and see what can be done, but I am not feeling confidence that anything will change.

Has anyone else had to jump these hoops?  Any advice?

I should say that here in Oregon there is no State disability, this is a private disability insurance company that is a benefit from work and and has been payed into for my DH for the last 33 years.

JJAz

If he wasn't diagnosed by a neurologist, that's where you need to go to get this process going. It's not going to be enough for your PCP to talk to a neurologist.  Find a neurologist that is interested in treating dementia patients.  Not all of them are.

Mama Cass

thanks.  I have been advocating for a neurologist from the beginning.  Kaiser doesn't seem to think it is necessary.

Now my husband is declining visibly.  He cannot do simple math in his head and this last Saturday wasn't sure where he was when we went to a usual place to visit friends (who he didn't remember all of).

Crushed

you need a lawyer yesterday   your problem is not Kaiser its the disability insurer

you dont have ages in your profile SS disability is federal not state

Iris L.

You need to have your medical documentation in order or SSDI will deny.  He needs comprehensive neurocognitive testing and other tests.  How old is he?  I had the same problem and had to sue my employer for my private disability insurance benefits.  

Iris L.

Crushed

Iris L. wrote:

You need to have your medical documentation in order or SSDI will deny.  He needs comprehensive neurocognitive testing and other tests.  How old is he?  I had the same problem and had to sue my employer for my private disability insurance benefits. 

Iris L.

neurocognitive testing is not "biological evidence".  Which is why she needs a lawyer . 

YESTERDAY  I'm a lawyer and i hired a disability lawyer

kaiser gave me a detailed physican's statement supporting the diagnosis

They have substantial expertise in this area

The clearer the case the less you need a neurologist.  psychologists do neuro cognitive testing but MMSE is accepted for almost all diagnosis with a proper history The problem only comes up when a patient like DW is declining from an extremely high level of capability

Iris L.

I had no problem being approved for SSDI with the same medical documentation I presented to my employer/insurance company.  They just wanted to give me a hard time.  Once I hired an insurance claim law firm, they came around without further ado.  Meaning they finally accepted my medical documentation.  I'm not saying legal representation may not be necessary, but that there has to be medical documentation to go on.  

At one time a doctor said I was "bummed" about an imaging study result.  I didn't even know what he meant by that, since it was not a term I had ever used.  Nevertheless I was dropped from disability insurance.  I had to file an appeal to get it reinstated.   I don't want to say that this is a game because that is not the correct word but there is a lot of nuance in this area.  It is not straight-forward.

Iris

Crushed

Iris L. wrote:

Once I hired an insurance claim law firm, they came around without further ado.  Meaning they finally accepted my medical documentation.  I'm not saying legal representation may not be necessary, but that there has to be medical documentation to go on. 

Very common problem,   Fortunately in most states the bad faith refusal to pay an insurance claim is an independent tort. 

 . In performing their duties, insurers owe a duty to the insured to act in good faith
and to deal fairly with the insured, particularly in the claim handling process. The insurer’s improper and often
egregious handling of an insured’s claim can give rise to extra-contractual claims like bad faith claims. An insurance
bad faith claim describes a claim that the insured may have against the insurance company for the insurer’s bad
acts in not adhering to the implied covenant of good faith and fair dealing.
Some examples of insurer’s bad act:
• Unreasonable delay in handling, processing, or resolving claims
• Inadequate investigation or failure to investigate
• Unreasonable interpretations of an insurance policy
• Refusal to defend lawsuits or threats against the insured
• Unreasonable settlement offers
• Failure to settle third-party actions

 http://www.lexisnexis.com/supp/LargeLaw/no-index/business/insurance-bad-faith-claims.pdf

 That is the nuclear option lawyers bring to the table in relevant states

 

  

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Iris L.

Crushed wrote:

 

Very common problem,   Fortunately in most states the bad faith refusal to pay an insurance claim is an independent tort. 

I had no idea about this!  My insurance firm, which was a large insurance claim firm that practiced in several states,  never brought this up.  They did tell me that I could file to have them pay my legal fees, but they would fight it, and did I want to risk that? I was in such bad shape medically that I could not handle any more delay or actually anything. I think I would respond differently today but it's now several years later.  

My employer was also a large insurance company that offered services in several states.  I knew they could draw things out for a long time.  

My legal fee came to $70,000, although they only spent $500 on my case.

Yes, gather your medical documentation and get the most qualified lawyer you can find.  

Iris

Battlebuddy

  The first year my husband was diagnosed we went on short term disability as he was working. Before the disability went to long term disability, the insurance company decided to drop us. My husbands testing had  come back inconclusive.The problem was DH tested in a few parts saying he had severe Alzheimers and the tester didn’t believe his scores. 

   We got the neurologist to do anMRI that showed shrinkage and a PET scan that showed ALZ . Both I think would be biological evidence . 

   But the insurance company still didn’t accept the evidence. They just wanted to drop him and see if I would put up a fight. I ended up threatening to sue them. The next day they called back and all was fine. 

   So be prepared  to get tough with them. You have been given good advice here. I hope you get what you  deserve

Crushed

Victoria2020 wrote:

Bad faith? I wish . No bad faith possible under ERISA, don't understand why Crushed mentioned that.

Because your statement is not true as a blanket statement of law.  It varies state by state and who the employer was (state v private) and where they were located.  For example

mInnesota law states

  

 No policy, contract, certificate, or agreement offered or issued in this state providing for disability income protection coverage may contain a provision purporting to reserve discretion to the insurer to interpret the terms of the contract or provide a standard of review that is inconsistent with the laws of this state, or less favorable to the enrollee when a claim is denied than a preponderance of the evidence standard.

Erisa has a provision allowing states to regulate insurance .  I agree it is a very complex issue and requires an Erisa attorney if Erisa applies  we don't know yet that it does or what state is involved

Jo C.

Hello Mama Cass; I am sorry you are having this issue; it must be very frustrating, especially in a large HMO setting, but you do have options before seeking an attorney which can carry significant expense.  Kaiser is usually pretty good at assisting Members through such situations and has dedicated departments to do just that.

Your pathway into resolving this within Kaiser would be through your local Member Services Department that can advocate for you or supply information for an advocate for your needs.  NOTE:  Look on the back of your Membership Insurance Card; there you will find the telephone number for Member Services in your area. Give them a call - be sure to provide communication of your facts.  Provide the information that your husband is unable to speak for himself as he has Young Onset Dementia and is disabled;  then explain that you have been refused a specialty referral to a Neurologist for your husband by your husband's PCP and specifically why you need such a referral as in:  You need specialist confirmation of the diagnosis with written medical report of the same as it is required for application for Disability Insurance Qualification and this will be your source of income.  Kaiser Permanente is usually circumspect in problem situations such as these including needing getting through denials and obtaining referrals.

NOTE:  For future reference after this problem, in many service areas, Kaiser actually has Outpatient Dementia Clinics staffed by professionals; usually RNs, with a Physician Director who is most often, a Neurologist; the RNs can actually make referrals to specialists as needed and are skilled at navigating such situations.  If you do not know if your area has such a clinic for your future use, Member Services for your area can also assist with that information. 

Did you explain clearly and thoroughly to your husband's PCP why your husband needs that referral to a Neurologist?  If so; then did he/she explain why the denial for the referral - and was it because it was not, "medically necessary" or other explanation? Hopefully, you have been able to communicate to him/her the necessity for this referral is in order to provide the mandated specialty medical information for the Disability Insurance process which will be your source of income - Neuro would be the specialty to confirm (or re-confirm) the diagnosis and provide the mandated written medical report. (Your explanation which would perhaps be helpful to get the PCP from denial to approval.)   Squeaky wheel and a small bit of "dramatic"firm input often opens doors.  In other words; we are our own advocates and we have voices to be heard.  Also; giving the PCP a hook upon which to hang his or her hat for referral rationale is also helpful in some situations  as referrals to specialists and specialty services can be part of the PCP practice screening in some large organizations.  Don't know whether this is so in Kaiser, but hat hooks do come in handy in many situations that waffle a bit. 

If you do not feel that this PCP is a comfortable provider for you and your husband, not just in this situation, but generally overall, you can request a change to a different primary care provider.

For future reference regarding medically denied services, per Kaiser:

"A Member has the right to file a complaint or grievance when they disagree with treatment plan decisions not to authorize necessary medical services to not paying a claim.

Expedited appeals are available for medically urgent situations."

While your husband's need to see Neuro is not a medically urgent situation and does not involve his treatment, it also appearts to be a necessity need of another kind and referral would be appropriate. Just as in most areas outside of Kaiser, it may take a bit of time to have a Neuro appointment; that specialty is usually quite busy and highly booked.

Best wishes and good luck; do contact Member Services and when you have time, let us know how you are doing and how things are going; we will be thinking of you.

J.

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Crushed

Victoria2020 wrote:

 

Oregon was mentioned in OP.

So what ?  They live in Oregon now that has nothing automatic to do with what law applies.

people retire to other states

Mama Cass

Thank you.

Since this post, my DH has gotten a referral to a neurologist.  It took almost 2 years for this to happen and me explaining to the PCP that our income was in danger because of it.

PCP said he was not sure another MRI would show anything.  The first one two years ago did not.

Kaiser had no outpatient services to offer.  In fact all I got was a call with a Social Worker who sent me a bunch of websites for things like in home care.

I was told they have NO services or help to offer themselves.

I will call member services and see if I can get an advocate.

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Jo C.

Unfortunately, an MRI is often negative for diagnosing Alzheimer's Disease.  This was so for my LO who had three MRIs over a two year period.  What DID finally show that there was dementia was a SPECT Scan that our Neurologist ordered; that was successful for us, but I would imagine not for everyone.

Since MRIs can be problematic, a Neurologist's medical report clearly stating the diagnosis in detail and disability should suffice.

As for Kaiser; we are in SoCal and in the area we are, there is an outpatient dementia clinic.  They also have a very robust Geriatric Clinic/Program which sometimes, younger patients with certain diagnoses can be enrolled in - they usually are very good at services such a population needs .  I do not have Kaiser insurance, but am familiar with their structure in our area.

I do not know if you are near a Kaiser medical center (hospital) with nearby clinics or not; in such a setting, one will often find greater breadth in programs.  Getting to Member Services and finding an advocate to help you through the system will hopefully be helpful - it can be difficult to learn how to wangle one's way through the Kaiser system and it can be frustrating.  Hopefully there will be an advocate in Member Services who can assist you in getting the services and information you need.

Complaints are usually taken seriously at Kaiser; they depend upon their reputation for gaining and retaining Members.   Be firm, be concise with details and go from there.  Always polite without ever being insulting to a representative - get them to WANT to help you; insulting interactions most always shuts down the willingness of a representative to go the extra mile to help.  Over the years I have learned this and became quite adept at it - but it can be exhausting to have to go through the mechanics of it all on top of everything else.

So hope that you get all the ducks in a row to succeed in the disability approval.

Let us know how it goes.

J.