Short Term Disability denial

[amc80]

My state does not provide STD, but my employer does (the employee pays for the entire thing and has to enroll). I signed up for it during open enrollment in October of last year, for coverage starting 1/1/16. Eventually, I received a Statement of Health for that had to be completed, which I did do in January (which is when I received it in the mail).

In late December, I found out I was pregnant. I knew it could be considered a preexisting condition, so I called and spoke to someone at the insurance company. I was told that as long as I didn't receive treatment for it in the 90 days prior to the start of the plan (1/1/16), then it was fine. GREAT.

Fast forward to February, I get a letter saying my STD has been denied due to pregnancy. After a lot of phone calls, I found out it's because I marked I was pregnant on my Statement of Health form, which is an automatic denial.

My argument is that I wasn't pregnant when I signed up for the coverage, and the only reason there was a delay in my handing in the SOH form was because that's when I received it. The insurance company told me that because it's a group policy, my company can tell them to just approve it. My company (of course) is saying that is incorrect information and can't be done.

Am I screwed? Had I completed the SOH form when I enrolled, it would have been fine. My HR department told me it was available online (which I didn't see/know) at that time. I filled it out when I got it in the mail. I feel like my STD is being denied due to a clerical decision as to when the insurance company decided to send me the form.

 

[azstonie]

First off, congratulations and I hope all is going well and you feel well!!!

Secondly, KEEP AT THEM. Both entities and most particularly your employer. I think with constant pressure you would prevail. I think you have a handle on the "why" of this and NO MAN would allow themselves to be denied such an important BENEFIT at such a time in their life/their families lives. Talk to HR every day about this, email every day, etc. Tell them there is nothing more important to you and you will not just sit in the WOMEN ONLY CORNER regarding this.

 

[azstonie]

I have been giving this thought.

Consider: If you don't get approval very soon, get a lawyer to write a letter to your HR advising them that they are discriminating against you in your position as a pregnant female employee. You simply want the benefit your company offers, for which you signed up. It is unfortunate there was not adequate oversight/training by HR for employees who must apply for the benefit, but nonetheless you are an employee, you signed up for it, you are entitled to it. and you're not going away. If HR won't approve the benefit in your case, then more work is going to be done on your behalf by XYZ Law Offices. Surely the benefit is not so large that a legal fight would be advisable.

 

[amc80]

Thanks AZ. I spoke (emailed) with an insurance attorney who said my fight is with HR, not the insurance company. I'm trying to decide which path to take, and am thinking about whether a letter from said attorney would be enough for my HR to realize I'm not backing down.

I asked a friend (also an attorney) and she said insurance companies generally deny first, then ask questions later. Most people don't fight, so the insurance company wins. I'm not going to let this go- I can't afford to, since not having this coverage would mean I'd be without income for 8 weeks (DH makes significantly less than I do).

 

[MollyMalone]

* * * In late December, I found out I was pregnant. I knew it could be considered a preexisting condition, so I called and spoke to someone at the insurance company. I was told that as long as I didn't receive treatment for it in the 90 days prior to the start of the plan (1/1/16), then it was fine. GREAT.
* * * My argument is that I wasn't pregnant when I signed up for the coverage, and the only reason there was a delay in my handing in the SOH form was because that's when I received it. The insurance company told me that because it's a group policy, my company can tell them to just approve it. My company (of course) is saying that is incorrect information and can't be done.

Am I screwed? Had I completed the SOH form when I enrolled, it would have been fine. My HR department told me it was available online (which I didn't see/know) at that time. I filled it out when I got it in the mail. I feel like my STD is being denied due to a clerical decision as to when the insurance company decided to send me the form.

I'd be surprised if the look-back period for pre-existing conditions, re a policy that gives you 2016 coverage, begins on the date in October when you signed up. And even if you had filled out the Statement of Health before you learned you were pregnant, you wouldn't necessarily be better off; they could ascertain that you became pregnant in the 90 days before January 1 & deny your claim for benefits on the ground of pre-existing condition.

I gather you had not received a copy of the actual policy in late December when you called the insurance company. Do you have it now -- or is it available online; that should clarify precisely when the look-back time frame begins & what the insurer's definition is of "pre-existing condition". Although this Aetna sample has a 12-month look-back period, the definition is a standard one in my (personal) experience; you'll see it would "knock you out of the box" even though you had no obstetrical complications before January 1:

What is the definition of a pre-existing condition?
It means a condition for which the insured has received medical treatment, consultation, care, or services, including diagnostic measures, or for which they’ve taken prescription drugs or medicine in the 12 months just prior to the effective date of coverage. A pre- existing condition can exist even though a diagnosis has not yet been made.

Before you take any action, nail down the precise terms of your specific policy as written, so you know whether what you want is (a) what you're entitled to under the policy, or (b) outside-the-box leniency.

Good luck with this, and all best wishes for smooth sailing ahead!

 

[amc80]

I'd be surprised if the look-back period for pre-existing conditions, re a policy that gives you 2016 coverage, begins on the date in October when you signed up. And even if you had filled out the Statement of Health before you learned you were pregnant, you wouldn't necessarily be better off; they could ascertain that you became pregnant in the 90 days before January 1 & deny your claim for benefits on the ground of pre-existing condition. I gather you had not received a copy of the actual policy in late December when you called the insurance company. Do you have it now -- or is it available online; that should clarify precisely when the look-back time frame begins & what the insurer's definition is of "pre-existing condition". Although this Aetna sample has a 12-month look-back period, the definition is a standard one in my (personal) experience; you'll see it would "knock you out of the box" even though you had no obstetrical complications before January 1: What is the definition of a pre-existing condition? It means a condition for which the insured has received medical treatment, consultation, care, or services, including diagnostic measures, or for which they’ve taken prescription drugs or medicine in the 12 months just prior to the effective date of coverage. A pre- existing condition can exist even though a diagnosis has not yet been made. Before you take any action, nail down the precise terms of your specific policy as written, so you know whether what you want is (a) what you're entitled to under the policy, or (b) outside-the-box leniency. Good luck with this, and all best wishes for smooth sailing ahead!

I have read the policy. A pre-existing condition is defined as a condition for which you sought medical treatment for in the 90 days prior to the policy start date. It specifically states pregnancy is treated as any other condition. It does not mention anything about it being able to exist without a diagnosis having been made. I'd also assume that if that were the case, they would have mentioned it by now and ended this for good.

 

[diamondseeker2006]

Molly, you are so helpful with these legal matters!

amc, congratulations! I hope this can work out in your favor! If you can find the info, Molly is a great one to help you determine what is allowed under that policy.

 

[Puppmom]

AMC, I feel hopeful this will work out based on the language you've quoted from your policy. I'm sorry you're dealing with this anyway though. No one likes to feel like they're being taken advantage of or getting the run around.

 

[amc80]

Thank you, everyone, for your input. I love PS for this reason- so many educated people willing to help others out!

 

[GlamMosher]

Hmmm I work in this industry, although in another country.

Our policies would not pay a benefit for a normal pregnancy anyway. Are you saying that this policy should pay you a maternity leave benefit of 8 weeks? I can't say I blame the insurer for declining cover then when you have only taken it out just before getting pregnant.

Pre-existing condition exclusions are there to stop people signing up when they know they will need cover soon. It benefits us all in that it keeps premiums down.

 

[amc80]

Hmmm I work in this industry, although in another country. Our policies would not pay a benefit for a normal pregnancy anyway. Are you saying that this policy should pay you a maternity leave benefit of 8 weeks? I can't say I blame the insurer for declining cover then when you have only taken it out just before getting pregnant. Pre-existing condition exclusions are there to stop people signing up when they know they will need cover soon. It benefits us all in that it keeps premiums down.

I agree with you, and I know prior plans I've had have had a 10 month black out period (from plan start date) for pregnancy. This plan doesn't have that. If I had been pregnant when I signed up, I would totally understand the denial. I signed up during my employer's open enrollment when I was not pregnant (with no plans to get pregnant anytime soon). If I would have received and filled out the SOH form right when I enrolled, my coverage would have been approved. The problem is it took them three months after I enrolled to send the form, and I didn't receive it until after my coverage was supposed to start.

 

[amc80]

Also, based on the plan's language, my pregnancy shouldn't have been a pre-existing condition.

 

[azstonie]

My experience at every large entity I've worked is that the insurance companies pay per the directions of HR/the company.

I worked in Labor Relations for about a year and this is what was negotiated with the insurance companies the state worked with over the years. We would have gotten a much cheaper cost if we had approved the insurance company doing that "deny first, deny second" BS but we didn't want that.

I wasn't clear above, your 'problem' is your company/HR. The insurance company will perform per their instructions.

Go get 'em.

 

[amc80]

My experience at every large entity I've worked is that the insurance companies pay per the directions of HR/the company. I worked in Labor Relations for about a year and this is what was negotiated with the insurance companies the state worked with over the years. We would have gotten a much cheaper cost if we had approved the insurance company doing that "deny first, deny second" BS but we didn't want that. I wasn't clear above, your 'problem' is your company/HR. The insurance company will perform per their instructions. Go get 'em.

And that's exactly what the insurance company told me. But my HR is saying that's not true, which I know is BS.

 

[MollyMalone]

I have read the policy. A pre-existing condition is defined as a condition for which you sought medical treatment for in the 90 days prior to the policy start date. It specifically states pregnancy is treated as any other condition. It does not mention anything about it being able to exist without a diagnosis having been made. I'd also assume that if that were the case, they would have mentioned it by now and ended this for good.

Whew, that's great it says "medical treatment"! (I'd still be concerned on your behalf if it said "medical care", because "care" can include merely seeing a doctor).

I touched bases with Julie, my office's benefits claims administrator, yesterday afternoon to see what she might offer about your situation; she isn't in our non-profit's HR department, but rather is employed by an outside, 3rd party outfit. Although practices and policies obviously vary, she is less convinced than you and aztonie that the insurance carrier would/will agree to accept you as an insured upon your employer's say-so. Rather, she said there are 2 basic, disability insurance scenarios -- neither of which is your situation -- where the employer's input-lobbying can be determinative:

(1) Where the insurer offers a policy whereby it waives its usual, pre-existing condition exclusion for employees who "sign up" during the open enrollment period -- but due to a snafu, an employee's application is not in the open enrollment batch(es) sent by the employer, or it went MIA/unrecorded on the insurer's end after being transmitted by the employer as part of the open enrollment group. The employer's assurance to the insurance company that the employee did indeed sign up during the open enrollment period will resolve that kind of declination.

(2) When the employee is under the policy's umbrella & then actually "goes out" on disability, but insurer declines to make, or continue, benefits payments to employee on the ground that s/he is not disabled within the meaning of the policy within the claimed-for time period(s). This is the classic "deny first, pay later (if at all)" routine often seen re long term disability claims (rarer, Julie says, with STD benefit claims). But you are not an insured, so it's not a matter of the insurer refusing to pay out on a claim; they've declined to insure you in the first instance.

Since you did not seek medical treatment from your pregnancy from October 1 - December 31, and therefore your pregnancy is not a pre-existing condition as defined by the policy, Julie thinks your best bet (i.e., most expedient that's in your control) is to find out what the insurance company wants as documentation of no medical treatment & submit that ASAP, if you've not already done so. I'm not sure if your I'd also assume that if that were the case, they would have mentioned it by now and ended this for good means that you have formally appealed the denial of a policy or submitted something in writing from your OB attesting to the fact that s/he did not treat you before January 1?

 

[amc80]

Molly- Thank you so much for the reply and for taking the time to ask around. To answer some questions/clarify things:

It does define "medical treatment" as seeing a doctor, getting medication, lab work, etc., but I didn't do that until after 1/1.

I have not officially appealed. I think your idea is great- I will get my OB to write something saying I wasn't seen until after 1/1. I'm sure the insurance company will just come back saying "that's nice, but you didn't fill out your SOH until late January, sorry." But I've got to try something.

 

[MollyMalone]

Fingers crossed for you, amc -- hope you can soon be doing a happy dance!!

 

[amc80]

I wanted to update this thread after having had a long conversation with HR. They are going to attempt to get MetLife to accept a SOH form as if it had been filled out at the time of enrollment. They agree with me that it's MetLife's fault for not sending this form out earlier.

If that doesn't work, they are going to further look into a manually approval, although it doesn't seem that will fly.

If all above fails, they are going to see about me working on a reduced schedule while on maternity leave. Something like I'd use vacation for the first four weeks, then "work from home" the second four weeks. Apparently, even if I check one email from home I am paid for an entire day, since I'm salaried.

Regardless, she did assure me we'd figure out a way for me to not be without income for 8 weeks.

 

[azstonie]

Excellent!!!!!