meauxna

Wow J, I must've had a premonition about this--I was going to write you about it today!

Congrats on a 2/3 success
Sounds like 100% to me!

dbark

I'm so glad for you, Jenney. It's a shame they won't pay for the whole time, but at least you've got most of what you deserve.

Rushman

Funny how some people are. I'd love a job where people phone me up and cuss and swear at me...I can see the challenge in that.

Sally

Maybe not the best job for someone with a history of panic disorder to choose.

Rushman

I havent got a history of panic disorder, I CAUSE panic and disorder.

Sally

Long may you continue to do so.

Just Jenney

Ok, I'm home from work, got a day off tomorrow so can stay up late and hang out online. Now that I have some time, just wanted to tell you bit more about what happened with the whole appeal thing (for those of you who care):

Maria from Aetna's Appeals Unit was great. She always returned my calls and let me postpone the start of the claim review until I felt they had everything they needed to proceed. As such I was able to get some additional time to collect a few more pieces of documentation to be considered for the appeal, and finally faxed everything on Feb 28th.

I kept my appeal really basic, actually. The "meat" of my appeal documentation were photocopies of my doctors' handwritten notes taken during my appointment sessions. I was most nervous about these, however, because both of my doctors (psychiatrist and psychotherapist) have HORRIBLE handwriting; I honestly don't know if Maria took the time to call to get clarification from them.

I also included "explanatory statements", one from each doctor, which basically outlined in the doctors' own words what my condition was, what their treatment plans were for me and whether they felt I could work or not. The most recent letter was from my psychotherapist dated in February, which ended with a comment like, "Based on my most recent evaluation of her, Jennifer cannot work as a Capital One call center supervisor." Pretty blunt, which makes me wonder why Aetna wouldn't approve anything past Nov 21st. (Is it a coincidence that my first visit with this doctor was on Nov 21st? Hmm...)

In addition to these explanatory statements and doctors' notes, I also included an affadavit from my mother. In it she basically explained how she had helped me and for how long. She also explained that my need for such excessive assistance was out-of-character and, in her opinion, evidence of my disability, since I am normally very self-sufficient.

When I got news that the claim was only approved for 90 days' coverage I was seriously contemplating appealing that as well. Considering that I was still seeing my doctors through January (I had to stop when we switched our insurance plan) I'm not sure why I wasn't covered for the entire period. But then I started thinking about it, and decided I don't want to keep adding stress to my life by going through it all again. I wasn't expecting to get approved for ANY of it, so I'm happy with what I got.

Anyway... That's it! I'll feel 100% better about everything once I have the check deposited into my bank account. I talked to Capital One's HR dept the other day and they said the check was forthcoming, so I'll be looking for it. And then I can kiss it goodbye to help pay off some of our debt!

~ Jenney

Just Jenney

Oh -- I almost forgot...

If you read the rest of the thread, you'll know that my first appeal was denied because Susan (case handler) decided that my appeal was essentially "too thorough" to have been done by someone suffering from my kind of disability. In other words she based her decision NOT on the medical evidence provided but rather on subjective opinion, which goes against Aetna's own decision-making policy. This was the denial reason Susan told me over the phone; Maria told me that she did not see Susan's denial reason in my file. Some of you encouraged me to try to get Susan's denial reason in writing.

Well, I DID.

I called sometime in February, I believe, and asked a rep (not Susan) to send me a copy of all the notes in my file -- after she told me that Susan DID include her denial reason in the notes. What I didn't realize before that was that because Susan and Maria work in different units, Maria wouldn't necessarily see Susan's notes and vice-versa. I got the notes about a week later. Susan had written the following:

“the quality of the document that was sent by the employee seemed to suggest that she had no functional limitations..."

So, there you have it: Susan admitting, officially in writing, that she based her decision on the quality of the document and NOT on the content of the medical evidence.

I am thinking of filing a complaint against Susan and Aetna in general. I still have all my notes about all the mistakes and miscommunications that were made; it's just a matter of updating them and making specific reference to this denial reason. It goes against Aetna's own written policy. But I'm not sure I want to spend my energy and time doing that now. I wouldn't do it to try to get more coverage, but for the principle.

~ Jenney

cindyabs

Congrats Jenney! I would say that IF you felt you still needed closure on this than you could pursue it, but otherwise you certainly have stood up for yourself and your persistence has paid off.
Good for you kiddo!!

yorkshire_lass

Oh my god! I can hardly believe the awful trouble you have had with all this! but good on you for sticking with it and demanding your rights. Who the hell does Susan think she is to be deciding on your capabilities?? amazing and shocking! I would feel like taking up a case against her or the company for aggravating my condition if I were you, but maybe you would rather just leave it and move on, and maybe that would be better for you.

Reading this has been a real eye opener for me as to how different things are in the US and UK when it comes to these situations. I took time off my job due to a stress related illness when I was in the UK, all I had to do was see my GP and he wrote me a sick note which I sent into work at the start of each month, and I was paid in full for three months, then half pay for another three. Aren't there any laws to protect people from added stress if they are suffering from these type of illnesses? I know I would definitely needed help to have been able to compile the sort of paper work you had to but to be told that if I did I was displaying ability to do my job (and thereby being basically accused of faking my illness) would have been horrible, especially coming from someone who is not qualified to know what you are or are not capable of doing. Thank goodness you had your mother and relatives to help you sort it out. Terrible situation. I am glad you got it sorted, I wish you well in your new job. and I hope I never get ill whilst living in the States! eeek! :scared:

Jerseygirl

I too hope I never get ill while living here. You have sort out all your own doctors, hospitals, collect and deliver your own x-rays, test results.
I know a woman who had breast cancer and she told me that fighting cancer was nothing compared to the fight and stress she had with her medical insurance company.

TruBrit

nahhh still got me bupa going...if i'm ill it's first flight outta here

Jerseygirl

Yep that's what we planned on doing when I had a 'scare' couple of years ago.

Just Jenney

This was actually not the first time I had to deal with an Aetna disability claim. In March 2004 I was diagnosed with having a benign tumor wrapped around one of my salivary glands, which was removed that July. One of the side effects of the surgery was that the left side of my face was totally paralyzed for about three months. The worst of this was that I could not close or blink my eye, so I suffered from rapid deterioration of my left eye. I couldn't read or use a computer for more than a few minutes at a time, and couldn't drive, so I was out from work for those three months.

I filed a disability claim and although it wasn't denied, I was given a major run-around by Aetna. The rep kept saying that she didn't get the medical documents from my eye doctor's office, and I had to ask them to fax the docs repeatedly, then follow-up. Since I was seeing my eye doctor every two weeks, this happened frequently.

In October, at my request my doctor wrote a "stay-out-of-work" directive on a prescription note to allow me to stay out of work until Jan 1st or until I got better, whichever came first. I left a phone message for the Aetna rep telling her that I was still out of work, my doctor cleared a continued leave of absence through the end of the year, and that I would let her know when I was going back to work again full-time. Only when I did this a month later did she say, "You were supposed to be back at work this entire time, so your disability coverage has already ended." I had to tell her about the prescription note to get her to acknowledge that she had indeed received the proper paperwork from my doctor, meaning she was either totally incompetent or simply lying before.

All this when I had a physical disability that was obvious just by the sight of me. I was starting to get to the point where I thought I'd have to actually show up at Aetna's offices and let them have a look at my paralysis to convince them that I was, in fact, disabled and needed their assistance in processing my disability coverage WITHOUT hassle and second-guessing. Without having to prove myself to some faceless rep who couldn't care less about my situation and the hardship it imposed on us.

So, my advice to anyone who ever has to deal with insurance companies: WRITE EVERYTHING DOWN. Include dates and times of conversations, the names of who you talk to, what they said and what you said. That way, when they try to say that they never told you such-and-such or whatever, you can pull out your notes and say, "Actually, you told me this such-and-such at 2.39pm on April 30th." If I hadn't kept good notes I can assure you that my appeal probably wouldn't have been approved, and I would have also had far more troubles with my previous disability claim than I did.

~ Jenney

Sally

No pun intended