I have been off work since Aug 2016 due to profound hearing loss and vertigo and have been on Ltd since Dec 2016. I have a surgical date in Jan 2018 to complete a cochlear implant which will hopefully allow me to hear again.
I have asked for my insurance to cover the out of pocket cost of the implant ($6200) and was told no. I then asked about help with physio therapy that may help alleviate the vertigo and was again told no. Both of these requests were made after my case manager referred my file to rehabilitation services. They did however say if I needed any help with other devices, like perhaps a ergonomic chair to call them which was so not helpful.
About 6 or 7 weeks ago I declined a buy out offer from the insurance company but now, given the expenses I will be incurring is it possible to ask to reconsider the buy out? Has anyone done this in the past?
The must be really concerned that you may be permanently disabled after the surgery if they offered you a buyout this early in you claim. In this case they are stuck with you for a very long time.
How many percent from your future payments did they offer you?
What are the chances you will be 100% percent functional and able to work after the surgery?
the settlement was very small, about 1 yr Ltd benefits. I have not guarantee that surgery will work although the surgeon is optimistic. There are alot of unknowns though around the vertigo and my functioning hearing level allowing me to do my prior job.
I feel sort of cornered due to them not paying for therapy and we requiring it to deal with the vertigo. The physio is about $1000 a month and I believe if I don’t do it the insurance will cut me off. The implant cost is fine. I have been aware of that for awhile but the physio is a huge cost and without some kind of financial assistance there is no way I can pay $1000/month for an unknown length of time.
I guess I’m concerned now that I have declined the buy out I may have put myself in a very difficult position. Any incite is greatly appreciated.
Don’t they have other treatments besides physio? I think if you do other treatments and explain that you cannot afford physio they won’t cut you off.
Unfortunately, and maybe David could reply, the courts I believe have ruled that an inability to afford treatment is not an excuse for not doing so.
I think my brother’s mother in law had that surgery a few years ago.
There is no way she could work (she is retired anyways).
She can’t hear the phone ring (yes, she has a special phone).
I hope it gives you good hearing.
I would think don’t have to do treatment that “may” help.
I would like to hear David’s legal opinion on that.
Bubba - My insurer offered the same thing. I filed a claim in May/17 and in July/17 they were offering a buyout which was for just under a year’s payment but after taxes it would be less plus I have to split it with my Lawyer. Therefore, I’m not accepting it and am headed into “Discovery/Questioning”. I would like to understand why they won’t contribute towards the cochlear implant - is your LTD with your company’s insurer and does it cover any health benefits? Mine does which is why I’m asking. If yours does I would enquire from the Company exactly what benefits are covered. I would also ask the Insurer why they won’t cover the cochlear implant and if they state it isn’t in the policy I would request a complete copy of the Policy. This way you know exactly what you’re covered for and what you’re not. I’m also presuming you’re being paid LTD payments from this Insurer and if so - DO NOT take a buyout. I completely understand that financially this puts you in distress - it did for me also - I went an entire year without an income when they cut off my benefits last year - and then my Employer terminated my 36 year employment without severance “frustrated contract”. I refuse to go down - I’m suing both. Insurers have a policy to cut people off whether they have a justified claim or not because they get new clients in every month - thus cutting into their profits. If you can - my opinion is don’t let them take you down - fight for everything you can. Also exactly what “therapy” are they offering? I would request the Insurer give you a detailed message regarding the type of therapy and what it’s meant to do. My last opinion - GET EVERYTHING - AND I MEAN EVERYTHING - IN WRITING! The more that you have documented the better it is for a lawyer to fight them with. That was my one mistake. Although I had requested my Insurer contact me via email only - they switched my Case Manager 4-5 times - and none contacted me by email. I was too sick to even care when the phone rang. I wish I had just told them of my request and that I won’t speak to them on the phone and they must email me. Or I wish I had recorded my calls at the very least but I would have to tell them I was recording - either way - you need to document everything. If your surgery isn’t as successful (and I hope that’s not the case) you want to have yourself protected. In the long run it will benefit you greatly.
Thanks for the reply Caramel. I have no medical benefits with Ltd, which is the through my employer. My employer cut my medical benefits off at the 1 year mark. Interestingly enough I am not able to use a telephone to communicate due to my hearing loss but despite that I still receive phone calls about 90% of the time. When I get a phone message I have to forward it to my husband who then calls them back on my behalf. I keep being told they " forgot" I need to communicate via email. The man that called to offer the buy out told my husband they could not put a buy out offer in writing via email so he needed to get back to them via phone. I decided to email him directly to inform him that I was declining the buy out offer, more out of principal because it is my claim and I felt I had a right to reply on my own behalf.
The reason stated for not covering my implant is because it is surgical but they did offer a ergonomic chair if needed when I return to work, so helpful.
I also have extended health insurance through my employer.
When they fire me, I expect to lose my extended health.
The only thing I think I keep is my life insurance (don’t know why but the insurance company specified life insurance in my LTD approval).
Bubba - that’s absolutely ridiculous! However - verbal agreements hold absolutely “no water” in a court of law - it’s too hard to prove who said what. Therefore, if they aren’t willing to email an offer - they most certainly can put it in writing and MAIL it to you. I would not verbally agree to anything ever. Always get it in writing - and if via slomail is the only then that’s the way it should be. And don’t let them tell you they cannot offer it in writing because that’s a load of crap.
I don’t know what province you’re from but there must be some sort of medical coverage for you. This is not cosmetic surgery.
Also - ask the LTD provider for a complete copy of the insurance policy.
Jammer - I also had extended health insurance through my employer - and once I was terminated I lost my extended health. Life insurance is usually kept IF you transfer it (convert it) to an individual oolicy without having to provide evidence of good health or undergo a medical exam, provided you do so within 31 days of the date your group life insurance terminates or reduces. They will need to send you the documents. I had to request these from my Insurer because they didn’t send them. It will include a chart that gives you the fees (depending on your age). The annual rates are usually shown are per $1,000 of life insurance with the minimum partial conversion being $10,000. (i.e 37 yr old male - converting $30,000 to Permanent Life insurance (payable at death of insured - no premium increase):
Annually: Rate for Male 37 = $15.14 (per $1,000)
$30,000: $15.14 x 30 units
Annual Fee: $122.45
$15.14 x 30 = $454.20 + $122.45 = $576.65/year
Monthly:
$576.65 / 12 = $48.05/month
This type of fee isn’t hard to handle per month but as a person ages the rate per $1,000 goes up substantially. For me (55 years old) this would be mine:
$33.89 x 30 = $1,016.70 + $122.45 = $1,139.15/year
Monthly: $1,139.15 / 12 = $94.93/month
And that’s ONLY for a $30,000 permanent life insurance policy. Rates are cheaper for a non-convertible (temporary life insurance to age 65) but for me this is only a 10 year policy and won’t pay out unless I die at or prior to 65).
Hope that helps with any future decisions.
I am going to be preparing an blog article going into this subject. Before giving an answer and want to do a full review to see if there has been any recent judicial commentary on this issue. The starting point is that you have a contractual obligation to be under regular care of a physician and to attend to recommended treatment. Its not enough to say you can’t afford the treatment, you would also need to show you tried everything possible access the treatment via public health system and could not do so. You have to show you have pulled out all the stops so the judge would be satisfied you are not just making excuses.
David Brannen
Disability Lawyer with Resolute Legal
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Thanks so much for all the replies. I have spoken to my Dr and he has referred me to a specialist for the vertigo so the recommendation for physio is on hold for the time being. Given David’s response I would imagine I will be in a position to pay for physio down the road.
For now the plan is to have surgery Jan 2 and then mid Feb the implant will be activated and a sound processor attached. The surgeon feels I should be able to return to work 3 months after that. Praying this is the case and the vertigo disappears.
Again thanks for the responses, it helpful to know there are so many knowledgeable people to reach out to.