Suggestions for Filing
By Annie Bloom

Your application and all supporting evidence will be scrutinized by insurance claims personnel trained to find weaknesses that can be used to delay, deny or limit your benefits. Careful preparation in the early stages of your LTD claim is essential and can help you avoid common mistakes. Take your time and go through each step of the process slowly If you are very ill, ask a trusted friend to help you.

1. Obtain a copy of your complete LTD policy from your employer or directly from the insurance company; read it thoroughly before applying for benefits. Note: pamphlets that describe your benefits or certificates of insurance given to employees are not policies; if there is any difference in language, the language in the policy prevails.

2. Determine whether your LTD insurance is an individual Policy or an employee benefit. Most group LTD policies are employee benefits, which are covered under a federal law called the Employee Retirement Income Security Act (ERISA). Individual policies are governed by state laws which are usually more favorable to the claimant and allow suits to be brought against insurers for bad faith.

3. Understand all terms used in the policy, including disability, covered employment, exclusion or elimination period, pre-existing condition, special limitations for certain conditions and proof of claim. Insurers sometimes distinguish between being disabled from your job (the position you hold with your employer); being disabled from your occupation (similar work done for another employer); and being disabled from any occupation for which you are reasonably qualified.

4. Note all time limits that apply to eligibility, elimination period, providing proof of claim, appealing denials and filing a lawsuit; observe them carefully. Note how many hours per week you must be working to be covered for benefits, and whether you must be totally or partially disabled to be eligible. If you reduce your work hours due to illness, be sure to document the date you left full-time employment and obtain a letter from your doctor clarifying that the reduction in your hours was for medical reasons.

5. Work closely with your doctor(s) to provide the strongest possible evidence in support of your claim. Medical reports submitted with applications or appeals should include the following: a strong statement confirming your CFIDS diagnosis and your inability to work; detailed application of current CDC criteria and your medical history to support your diagnosis; documentation of all physical signs, abnormal lab tests and other objective evidence of illness; a statement that you are totally disabled and unable to do any kind of work, if applicable; a detailed explanation of how your specific symptoms limit or preclude any work activity; results of functional capacity or exercise tolerance tests, if possible, to support your inability to work; objective evidence that all other possible causes for your symptoms have been carefully excluded (lab tests, reports from specialists, etc.).

Throughout your claim, be prepared to provide ongoing documentation of all signs and symptoms that support your diagnosis and your inability to work. Your doctor may be asked to submit additional information, including office notes and written reports.

6. Be aware of two-year limitations. Many policies contain two-year limitations for mental illness and nervous conditions. Your insurer may look for reasons to classify you as mentally ill in order to limit your benefits. If symptoms of depression or anxiety must be documented, be Sure your doctor clarifies that they are secondary to the illness and did not exist before. New and renewal policies may also include two-year limitations for "chronic fatigue conditions," "allergies to chemicals or the environment" and "self f- reported" symptoms such as "chronic fatigue" and "muscle pain" which can not be confirmed by objective laboratory testing. These new limitations do not apply to existing claims filed under policies written before the new language was adopted.

7. Maintain a chronological file of all documentation and correspondence related to your claim, including your initial application, information from your employer and physician's statement; all medical information submitted; all letters from you, your insurer and your attorney; and any supplemental forms you complete. Review this file frequently to catch and clarify any details you may have missed, and note patterns of delays or denials. You are also legally entitled to copies of everything your insurer has in your file, including internal memos, reports from independent medical examinations required by the insurer and any surveillance videos your insurer has ordered from private investigators. Consult an attorney or your state insurance commissioner if you are denied access to this information.

8. Your LTD benefit is the maximum amount you can receive from all employment-related sources under most group policies. For example, any additional income you receive from part-time work, short-term disability, state disability, Social Security and some retirement plans can and will be deducted from your benefit amount. If you receive back payments from SSDI while receiving LTD payments, you may owe all or part of this to your LTD carrier. If other family members receive Social Security benefits due to your illness, expect your LTD insurer to deduct that income from your benefits, too. Determine what percentage of the premium (if any) is paid by your employer; the same percentage of any benefits paid to you will be considered taxable income by the IRS.

9. You have the right to seek representation by an attorney. If your LTD insurance is an employee benefit, look for an attorney experienced in ERISA law and handling CFIDS claims. Discuss fee arrangements in advance. Options may include paying hourly for assistance in writing letters, appeals and filing a civil suit; paying a retainer for a thorough review of your medical evidence and claims file, with additional time billed by the hour; or negotiating a contingency arrangement in which your attorney will receive a percentage of your benefits. The latter is commonly used when a case goes to trial. Weigh the value of your benefits against your estimated legal expenses. If you can't afford an attorney, look for a paraprofessional trained to advise disabled claimants.

10. Obtain legal advice early in the claims process. Strengths and weaknesses in the initial application can have a major impact on the outcome of your claim. If your insurer offers you a cash settlement in exchange for relinquishing your rights to future benefits, insist on being allowed time to review the offer in written form, weigh its merits and obtain qualified legal advice before signing away your rights. Many offers are ridiculously low, never put in writing or withdrawn after a short time.

Members of your local support group, bar association or disability rights groups may be able to recommend attorneys who have successfully handled ERISA claims for CFIDS patients.

11. Be sure to appeal denials within the stated time limit. Whenever possible, have an attorney draft your appeal, highlighting the strengths of your medical evidence, weaknesses in the insurer's denial and citing relevant sections of ERISA and other applicable laws. Remember that insurers do not care about the pain and hardships claimants must endure; they are only interested in the relevant facts of your case.

12. Strengthen your case by providing additional medical evidence when you appeal a denial; relevant articles published in peer-reviewed medical journals can be used to support your evidence. Also consider obtaining functional capacity evaluations or vocational appraisals by persons trained to assess your ability to work full or part time if you have not done so already Any of these strategies will also strengthen initial applications for benefits.

13. Be prepared for independent medical examinations (IMEs) by doctors paid by your insurer to evaluate your disability. Some insurers go out of their way to schedule IMEs with cynics who do not recognize CFIDS as a valid diagnosis. Try to find out about your examiner's experience and attitudes toward CFIDS and how much of their work is for insurance companies. Ask if you can bring an observer or tape recorder to the examination. Avoid appearing antagonistic, but be prepared to document any irregularities in the examination or indications of obvious bias by the examiner.

14. Expect difficulties after the first two years of your claim. Many insurers try to limit their liability to a maximum of two years of benefits. After two years, depending on the contract your insurer has with your employer, you may need to prove disability from any occupation to be eligible for further benefits. Also be prepared for increased frequency of IMEs, home visits, surveillance, harassment and attempts at intimidation.

Permission is granted to copy or quote articles for non-commercial purposes provided the intended meaning is preserved and proper credit is given to the author and The CFIDS Chronicle (including the postal address - PO Box 220398, Charlotte, NC 28222-0398 -- and toll-free number, 800/442-3437, of the CFIDS Association of America, Inc. © Copyright 1996, 1997, 1998 The CFIDS Association of America, Inc.

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