Private Insurance Nightmare

[Mishma]

When I went to work at a state university I took out long term disability insurance as well as long term care, knowing perhaps someday I would need both. No physical was required nor was I expected to divulge my HIV+ status. I worked for 14 years before I had to go on disability. The private insurance kicked in and paid me a portion of my income, made regular contributions to my TIAA/CREF retirement account, as well as covering my medical insurance premiums, meds and hospitalization.

So that is the backstory. Everything was running smoothly until about 2 years ago when out of the blue I got letter from one of the insurance companies indicating that I was being dropped from their coverage but I could appeal. And so appeal I did by hiring a disability lawyer. Here is what I learned.

The onus is on us to make sure the medical records insurance companies receive periodically ( in this case the VA) are accurate

We can appeal a denial of claim but it is going to cost $. In my situation $1000.00 with no reimbursement. 

Insurance companies routinely go after small fish too so that when a large settlement happens and they contest the claim, they can show no bias

Physicians can retroactively alter and correct their notes

If the case goes to trial and you lose it costs you nothing. If you win you get 2/3s of the settlement


How did this happen you might wonder. Turns out the basis of their denial was not information provided by my ID doctor but rather a poorly written, grossly inaccurate note from a psychiatric resident that I had seen.

It went something like this.

Mr. X’s bipolar condition appears to be stable and he going to take a job as a running coach at a local community college.”

What I told the resident was that I might volunteer a few hours as a writing coach at the local library.

After the discovery phase the insurance company promptly reinstated me. I was hoping they would take to me to court-I know the local AIDS foundation could use the money. I can laugh at it now but at the time I felt like a character in a Franz Kafka novel.

[Ocean1617]

I am not understanding the reason the insurance drop you because of the psychiatric resident's note. Did the note seem to indicate that you were able to work and not disabled? Is that why the insurance dropped you?

[gadawg1979]

Tort law is in your favor they have 24 months to find a problem after that fact you are covered.

[bocker3]

Not sure that I'd classify this as a "nightmare".  Seems that the insurance company was dropping you because it was told you were going back to work.  Once you let them know that this was incorrect, they reinstated you.  Unless there is more to this story, seems like a misunderstanding that got corrected as soon as the facts came out.  It's unfortunate that it cost you money and time, but I wonder if you could have gotten this straightened out without a lawyer if you had contacted the insurance company yourself.  Perhaps you did and didn't mention it -- but it seems like you went right for lawyer.
As for where the onus of correct data should be -- do you really think it's the insurance company that should ensure all the records they receive are correct??  That seems like that wrong place to lay the responsibility.

[Solo_LTSurvivor]

Tort law is in your favor they have 24 months to find a problem after that fact you are covered.

Do you care to explain how you arrived at this conclusion?  If you were attempting to apply the "but for" doctrine to find out where the exact proximate cause lies, you could go on ad nauseum.

But for the hospital/clinic hiring a resident to provide treatment, the OP wouldn't have been dropped from his coverage.

But for the OP not seeing a "trained" doctor instead of a resident, he wouldn't have been dropped because the doctor wouldn't have written up the case notes improperly.

Do you see where this is going?

If the OP wanted to attempt to bring a civil action for the tort of negligence, why wouldn't he go after everyone including the hospital/clinic/psychiatric facility, the doctor, the resident AND the insurance company?  After all, the blame could be equally distributed, under the law of torts, and with your line of thinking someone would have to make the OP whole.

Torts are not that simple generally.

[JessieJames]

You made a good decision hiring a lawyer. Don't take legal advice from a blog. 

I saw some discussion of Torts above.  There was no civil wrong here, this was an administrative law issue. 

Never go up against an insurance company on your own.   

[Solo_LTSurvivor]

Don't take legal advice from a blog. 

I saw some discussion of Torts above.  There was no civil wrong here, this was an administrative law issue. 

Exactly. 

The only administration in this particular situation pertains to whatever the process is for determination of what "disability" is based upon the guidelines - which is not the same as administrative law.

Administrative law specifically deals with regulations, standards, and adjudicatory decisions of the various administrative agencies created by Congress and the executive branch of government (on both the federal and state levels).  Unless something has recently changed and TIAA CREF miraculously became a (government) agency and is no longer a Fortune 100 company, then it would be necessary to go before an administrative law judge at a hearing to determine where the fault lay, and the judge would enforce the rules, as per the agency regulations.

The only reason I  brought up the subject of torts, is I was curious as to how one of the commenters on this thread felt that tort law applied to the OP's post.