Long Term Disability Law in PA

[karmstrong]

Greetings,

I have been a grants administrator in good standing with the same company for 13 years. In 1998 I became very ill and was diagnosed with auto immune hepatitis disease which kept me out of work for 18 months. I convinced my doctor to allow me to go back to work in the year 2000.

I applied for a job in another department and worked for about 3 years under doctor’s care. At some point during my 3rd year I was diagnosed with cirrhosis of the liver with the AIH.

I went out on sick leave on 4/15/05. After seeing my primary care physician and liver specialist, I subsequently went out on an indeterminate sick leave. My doctor felt that I had a nervous breakdown and needed both physical and mental recovery and treatment time.

Unfortunately, I did not stop working. Because of the AIH I proposed to my boss a flexible work arrangement which would allow me to work from home once a week. This arrangement ultimately caused me to work longer hours. After I completed my own medical leave and physician certification paperwork and went home on leave my boss continued to contact me with assignment after assignment for the next two weeks.

I finally contacted HR who told me not to answer the phone. For the first time in my life, at the request of my PCP, I started seeing a therapist and psychiatrist. I was then diagnosed with Generalized Anxiety Syndrome and Severe Depression--who knew.

I was so distraught that I began to pass out from time to time and suffer with severe migraine headaches which caused me to be seen in the emergency room on several occasions. The Psychiatrist prescribed a host of medications to combat the GAS and Depression. I was already on mid level doses of steroids to keep my liver functioning.

After fully exhausting my sick, vacation, and most of my short term disability, I was informed that I should either apply for long term disability or request a leave of absence without pay. I chose the long term disability because I would continue to get the medical benefits that I needed to cover my bi-weekly blood tests for liver disease and weekly appointments to the therapist and to cover the cost of my 6 prescriptions.

I was told by my employer that they outsourced the long term disability insurance to Aetna and I would need to apply with them directly. After speaking Aetna who informed me that I had to be out of work for at least 6 months before I could apply, I decided to do the foot work myself. I was being seen by my PCP, a Psychiatrist, Neurologist, Gerontologist, Gynecologist, and now a Rumotologist.

I took it upon myself to request medical records from each of the doctors as well as having each one complete the host of forms from Aetna. I finally received everything back in early December 2005. I sent Aetna via fed Ex my medical records from 1998 to 2005 along with a letter from me describing how my illness prevented me from working any job. Each doctor asserted that I would be totally unable to work for at least two years.

I received a return receipt letter from my employer on December 11th 2005 indicating that would be terminated on December 10, 2005. My salary continued until September 2005 and benefits until January 2006. My medical information was received by Aetna in mid December so I expected to hear from them (according to what I was told by their representative) in 2 to 3 weeks.

I was contacted today, February 10, 2005, and told that I was denied due to the description of a long term disability in my employers Summary Plan Description dated November 17, 2005 which states as of July 1, 2005 that an employee's clinical records must describe a medical condition that renders the employee completely disabled.

Of course my concern is that my last day in the office was April 22, 2005, which was prior to the revision of the policy. In addition, the previous policy has been deleted from the summary and no longer exists anywhere in the handbook. No one in HR seems to be able to assist me in locating it.

The representative at Aetna also mentioned that I should have been provided with this policy at the time of my leave. It was recommended that I wait to get the letter of denial, file an appeal and proceed with getting medical records and statements from my doctors (again) that agree with my claim.

My concern stems from my first medical leave in 1998 where I requested long term disability followed up with a doctor’s note indicating that I would be out for an undetermined amount of time - I was approved!

The wording in the policy granted long term leave and long term indefinite leave upon approval. The verbiage was not revised until July 2005. I don’t feel that I should have to go through requesting medical records all over again. Can you direct me as to other steps I should take?

[cbg]

Duplicate post answered elsewhere