Medical Coordination Benefits


#1

Hi There

I’m looking for some clarification please. In my policy book for benefits there is a section called Medical Coordination Benefits. It states that:

" Medical coordination is a process of early involvement to ensure that you are diagnosed quickly and receive appropriate medical treatment on a timely basis. The goal is to enable you to return to work as early as possible and to prevent the disability from becoming long term or permanent."

I live in the north and when I first got sick and I was having trouble getting a doctor (in the northern communities there is a travelling doctor who visits every 2 weeks and changes) I reached out to my insurer to get help getting medical care. I’ve reached out multiple times and then gave up. I’m now almost 3 years off of work and my symptoms are still undiagnosed and worse than when I first got sick. I tried to explain to them that getting referrals take forever up here - I’m currently on the wait list for a few referrals and my doctor just informed me that I might be waiting over a year for some. My insurer did not comply with this portion of my policy. I feel because of it I have suffered longer than I need to. Is there anything I can do? What happens if they did not comply with this portion of the policy?

TIA


#2

My husband is in a lawsuit over this clause with GWL. In his master policy there is even an expense amount available.
Document their denials–put your requests in writing or request your claim file.


#3

When I did ask for help it was in year 2015 and 2016 over the phone. After being screwed over with other phone conversations Im doing everything in writing but I haven’t asked for help this year. Should I send an email to my case worker and bring this clause up? The other thing is that my insurer changed my case workers a handful of times (no warning or explanation) with the exception of one which I requested be removed from my case because she wasn’t doing her work and I ended up not getting paid a few times. What happens to the insurer if they have not abided by this clause? The reason I want to know is because now I have so many symptoms and theyve gotten worse over the years. My doctors say all I can do is manage my symptoms but it’s not good enough. I’m looking into a naturopath but would have to pay out of pocket. Also I think that if they had helped me I would be back to work by now.
I’m also frustrated because they just got my CPP lump sum payment which would have been helpful for my medical bills. I just feel like they have been no help.from the start and I have suffered as a result.

If you sue what is the reason you’re suing?


#4

My spouse is suing for his medical benefits being wrongfully terminated. As well as being lied to that he had to file for CPP Disability (when he did not)

See this post about medical coordination and vocational benefits LTD cut off due to "Non Adherence"


#5

So should I bring this up and ask why they haven’t helped me get access to faster medical care? They are reviewing my case now - the medical board. They tried to get me to get back to work and said that my psychiatrist recommended a bunch of things which she did not. She wrote them saying that they twisted her words and that she will only communicate in writing right now. They just got my retro pay for CPP D so I’m nervous that they’re trying to find another way to get me off of.benefits. the funny thing is if they had just helped me when I asked I might be back at work by now. So should I bring up this clause or what should I do?


#6

I would not bring it up while under review. You asked twice before–do not ask again. If they make a move to try and stop your income benefits then speak to a lawyer and use the lack of help against them.
It is fantastic that your psychiatrist set the record straight and since you are getting CPP-D their payment to you is reduced.
They are not in a good position to go against your specialists/doctors.
My fear is their medical board is going to advise that they try medical coordination or vocational assistance for you.
That is all about stacking a claim file with medical reports that can be used against you.

In other words-be careful what you ask for. Anytime an Insurance Company spends money it is to save money,


#7

They maybe considered bad faith conduct and at very least will reflect poorly on them if you have to take your case to a lawsuit. Usually, they have the discretion on when and if to pay for rehabilitation…but in situations like yours, I agree the wording seems to go beyond that and implies they will place greater emphasis on helping you access services.


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 reliabile 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 1-877-282-5188 to speak with a member with our disability claim support team._strong text


#8

So I requested my claim file and my case manager just got back to me saying that he can’t send any part of my claim file that has to do with my mental health and that I would have to ask my doctors for these portions - Is this correct?

Also he said that he cannot send my master policy and that I would have to contact my employer for this - just wondering if this is correct Also?


#9

You can request that they send to your family doctor, the mental health portions, and you can pick it up from there. Personally I feel this is discrimination.

The master policy can be requested from your employer. It would be nice to have them denying you a copy of the policy wording in writing. Also that they have denied you access to your mental health records directly. They will say under PIPEDA they do not have to release, but that is not true.


#10

No, this is hogwash in my opinion. You have a right under federal law to your personal information. This is very patronizing and demeaning for them to take this stand. Perhaps they have some valid reason for this policy but I doubt it.

That being said, you are best to just have them send it to your doctor and you can get it form your doctor.


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 reliabile 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 1-877-282-5188 to speak with a member with our disability claim support team._strong text