Denied as I am not under active treatment


#1

As a contracted employee I have been paying Disability Insurance since 1991. This past June 2017, I applied for benefits. I have been diagnosed with severe osteoarthritis and severe degenerative disc disease. I do not take prescription drugs and have opted for medicinal marijuana, which helps relieve some of the pain that I experience in several parts of my body, daily. I called in August 2017 to find out status and again in October 2017. In October they told me that while I have sufficient medical information, my family doctor did not indicated my limitations. I immediately contacted my family doctor and she complied with their request with a 2 page letter. They also sent an independent “home visit” person to meet with me. I was pretty upset with this person as he said “well I think you are a youthful person and smart, you should be able to get employment, have you tried to get a job?”. I answered truthfully and said I did apply to a job in the medicinal marijuana field but was unsuccessful. Two days ago I again called to find out the status and I was told it was denied for 3 reasons:

  1. I am not under active treatment 2. I am able to perform daily living items such as bathing, feeding myself and dressing and 3. I applied for a job.
    I have never been offered by my rheumatologist or family doctor an “active treatment” although I do get cortisone shots in my hips every 4-6 months (is that not a treatment?) and I take government approved medicinal marijuana and must visit the clinic every 4-6 months. I am not wheel chair or bedridden and I can, with care on my part, continue to cook, feed myself, dress myself and bathe. Lastly it was pretty clear from the home visit I had that the person was almost pushing me to try and get a job. I would like to know if I could pursue this legally. Thank you.

#2
  1. Are you under your own occupation definition?
  2. Request a full and complete copy of your claim file-proof of receipt
  3. Request the Master group policy or Master policy for your plan

Never again let anyone into your home-and anyone reading this -do not allow that-meet them anywhere else!

Also seek a free consult-see if EI sickness benefits could be an option for funds

You can request a reconsideration-but please get the claim file. Find out who the home rep was–were they a regulated health professional?


#3

Ned, you seem like an honest person but insurance companies usually require you to be under an active treatment (medications, pain clinic, frequent visits to a doctor, surgeries, physio). They need an evidence that you are doing everything and using every treatment that medical field has to offer.

For example, google your condition and see what treatment options are offered on the internet. Most probably those are what you should be doing.


#4

Thanks Elaine for the information. It’s unfortunate that neither my family doctor or rheumatologist suggested that I enroll in a program as I would have if it had been suggested. I have found a hospital that provides a program; I intend to enroll in the program.


#5

Hello allyoops, I am not sure I understand question #1. In requesting a copy of my claim file from the insurer, would this include all of their reports? From the business card of the at home visit person, it does not appear that they have any designation other than “consulting” on their business card.


#6

Yes-request a full and complete copy of your claim file for your records. It would include all of the reports, or should. The report from the consultant would be of interest-since your Insurer seems to heavily rely on that for their denial.

Do they have any medical reports that differ from your Doctor? Or are they just relying on a non medical consultant over your treating Doctor?

It would be helpful to you if you choose to ask them to reconsider their decision (appeal) or if you choose to go legal or seek legal advice to have the file.

What is your policy’s definition of disability is very important.


#7

I would ask your family doctor or rheumatologist why that program was not suggested.
Maybe that is experimental treatment.