I’m looking for some advice on dealing with my insurance case manager and wanted to know if this situation is normal or something I can push back on.
Question#1 - Is a case manager allowed to approve a shorter leave extension than what my doctor has recommended? Or is that common.
Context:
My doctor recommended a couple month extension to my current Short-Term Disability (STD) leave, but a few days before my case manager approved me for a one-month extension. Based off a phone interview update of my progress.
I provided my case manager that update on what my doctor said and the completed doctor form.
When I didn’t hear back, I reached out explaining the doc appointment update, the case manager refused to look at my current leave window again. Saying that they won’t review until a few weeks before the one-month extension window they already gave, and leave length past that one-month extension would be decided upon then.
Question #2: If they can approve a shorter extension then what the doctor indicated, are they legally required to provide their medical reasoning for the decision, when asked by me?
Any context would be appreciated. I’m finding it difficult to work with this new case manager, as they often seem to misinterpret my emails, don’t appear to read them fully, and have become audibly frustrated with me during phone calls when I’m not understanding something.
Technically we have to prove our continuing disability each pay period, so although it’s annoying, I don’t think there’s much to be done about the length of the leave. For the case manager not reading your messages and so on I guess you could escalate it to a manager but I probably wouldn’t until it becomes egregious. Do though document everything and send an email confirming anything that was said orally.
When I first went on STD, my case manager would approve 4 week durations even though my doctor documented my prognosis as guarded with an unknown return to work date, and no return to work attempts within 4 months. One week prior to these four week approvals I just sent the case manager an email stating that nothing has changed medically, and that I was still unable to return to work. They quickly extended my STD for another four weeks. On the last extension, which would move me to LTD, the insurer just asked my doctor for an updated letter which they got and that easily moved me to LTD.
I agree with the above comments. Basically, they are are not required to follow your doctors opinion to that extent. They can approve a window like they did and re-evaluate once that window is closing. Your doctors evidence will be helpful when they review it again near end of the period. I believe the approach they are using here is more for efficiency rather than denying your doctors opinion per se.
David Brannen
Disability Lawyer with Resolute Legal
The response posted above is based on the limited factual information made available and is not intended as a full and complete response to the question. The only reliable manner to obtain complete and adequate legal advice is to consult with a lawyer, fully explain your situation, and allow the lawyer enough time to research the applicable law and facts required to give an adequate opinion. The basic information provided above is intended as a public service only, a full one-on-one discussion with a lawyer should be done before taking any any action. The information posted on this forum is available to the viewing public and is not intended to create a lawyer client relationship with any person. If you want one-on-one advice, please click here to request a free consultation or call toll free 1-877-917-7050 to speak with a member with our disability claim support team.