How Peony Appealed (and won!) Her LTD Case

pink-peony-watercolor-taylan-apukovskaHere’s a two-sentence brilliant analysis by Peony:

“Social Security’s primary concern is that you prove your illness interferes with your work.”

“LTD’s primary concern is that you are trying to rip them off, so they want hard medical evidence that you are sick.”

Peony applied for LTD for Chronic Fatigue Syndrome and won her case. It wasn’t easy (or quick or cheap), but she did a fantastic job with it. And even though nearly all her medical tests had come back “normal” she got approved for both Social Security and LTD. Here’s how she did it.


Peony’s Application

🌸 I filled out the paperwork application and followed all the instructions.

🌸 In my case, there was a telephone interview where the guy got all friendly and tried to trip me up and admit that I had been out in the yard doing stuff while claiming I was too ill to work.

🌸 He asked for a list of all my providers to date which I sent him along with the clinical notes to date.

🌸 I was also required to apply for Social Security by a certain date.

🌸 Because I have Chronic Fatigue Syndrome, there was no hard medical evidence that I was sick. It didn’t help that my doc kept writing down that my exams were “normal” and not including the fact that I was still showing signs of viral illness.

🌸 My claim was rejected due to lack of medical evidence. They said that all my symptoms were self-reported and there was nothing in my medical record to support my statements. They also claimed that since I twisted my ankle I must have been bouncing around doing stuff. And they said that I had taken myself out of work without consent from my doctor (this makes no logical sense).


Peony’s Appeal

My appeal was approved. I hired a lawyer to help. My appeal packet was three inches thick. Here are some of the things it included:

🌸 All the new clinical notes and test results since the first application.

🌸 All the FMLA (family medical leave act) forms my doc filled out for my work. My doctor had filled out these forms twice for me to take extended medical leaves. This is the documentation that the insurance company failed to ask for and my company failed to provide to them when I first applied.

🌸 The letter of approval from my work for FMLA leave and the email of approval from Human Resources for short term disability.

🌸 Affidavit from me detailing symptoms and how Chronic Fatigue Syndrome affects my ability to sit, stand, walk, carry things and perform my job function. This took a week of back and forth with my lawyer and was almost 11 pages long when we were done. We tried to capture everything.

🌸 Documents stating the cause of my twisted ankle (since this came up in the rejection letter).

🌸 Detailed descriptions of job duties and why I could no longer perform each duty. (More tips from Peony on How to Describe Your Job Duties).

🌸 Affidavits from my primary doctor, my Chronic Fatigue Syndrome doctor, and my Chiropractor all stating how sick I was, if they considered me able to work, diagnoses, and potential dates of symptom resolution (For Chronic Fatigue Syndrome the date was “unknown”)

🌸 Affidavits from my caregivers stating what I used to be able to do and how bad things were for me now.

🌸 Letter from my shrink. She was very careful in stating that my depression was secondary to the Chronic Fatigue Syndrome and NOT the cause of it. (I did NOT send clinical notes. My shrink and I discussed this at some length and neither of us wanted the notes released. They were both too personal and they didn’t have a lot to do with my claim. Of course the insurance company did request them and my lawyer interceded for me.) Some LTD companies put a cap on mental health claims. It’s important to get a copy of your policy and read it.

🌸 My application for a handicapped parking placard. My doctor had written down a diagnosis of Chronic Fatigue Syndrome on the form.

🌸 The letter from Social Security that said they considered me fully disabled and that I was eligible for full benefits. The fact that I was awarded my claim on my first try worked to my benefit.

🌸 Many of the same documents and techniques that helped me win Social Security also helped me win LTD. (Here’s How Peony Won Her Social Security Case Despite “Normal” Test Results)


Peony’s Tips for Lawyers

🌸 If you need to appeal, hire a lawyer. I’m not kidding on this one. This is a long tedious process and you’ll need the help. Yes, it has cost me $12,000 in legal fees but you HAVE to get the appeal right the first time since you aren’t allowed to submit any more medical evidence after the 180 day deadline.

🌸 Cost benefit analysis: I spent $12,000 in legal fees, but if I am disabled for life, this is in the vicinity of one million dollars in benefits. It is so worth it to get a lawyer involved at this stage.

🌸 Try to find a lawyer that knows about Chronic Fatigue Syndrome or Fibromyalgia.


Peony’s Tips for Tests

🌸 Get as many medical tests done as needed to help with your case. In my case, it was virology, endocrinology, neurology, rheumetology, neuropsychology and a Chronic Fatigue Syndrome specialist. Also MRI of brain, CT of abdomen, UT of the kidneys and UT of the thyroid.

🌸 Another good one to consider is a functionality test that would be done at a physical therapy facility. By the time I found out about functional testing it was too late to arrange for it before the 180 day deadline.

🌸 Chronic Fatigue Syndrome should be measured over two days to get an accurate measure of Post Exertional Malaise.  Most places don’t understand Chronic Fatigue Syndrome and don’t measure two days. If your test is all in one day, make sure you do something to make you crash first so the test is an accurate measure.  You can always overexert yourself the day before the test.

🌸 There are some facilities that do this testing two days in a row on Chronic Fatigue Syndrome patients to show how energy levels can’t be maintained. Learn more: How Dahlia Won Her LTD Using a Two-Day Test.


Peony’s Tips for Working With LTD Companies

🌸 Get a copy of the legal version of the company’s insurance policy. Normal policies have the exact definition of disability in them so you know exactly what evidence you have to produce to claim disability. Mine didn’t but that is another long rant about the arrogance of a research facility.

🌸 Keep things private. Don’t announce things on Facebook that would make the insurance company think you can function normally. They will ignore the fact that you spent the next week in bed for that one night of fun. Ask your friends not to post pictures of you on Facebook for the same reason. Just because you have all of your privacy settings in place doesn’t mean that your friend does. Their photos of you might be in the public domain and if they tag you your party night is now out for all the world to see.

🌸  Don’t do stuff in public that goes against what you are claiming. They will hire private investigators. It is cost effective for them to catch you carrying a grocery sack into the house. Again they have no idea that you collapsed in a heap and had to sleep three hours afterwards. All they know is that they have a photo of you carrying groceries.

🌸 Write down all deadlines in bold letters in a place that you will see them all the time. There are no grace periods! Expect to use overnight mail and fax machines a lot.

🌸 Start some sort of filing system early in the process. I get so brain fogged that organizing everything on a good day saved my butt when I had to find a lost piece of paper right now on a bad day.

🌸 LTD is done in stages and this will vary from company to company. Things will also vary depending upon whether the insurance policy is directly from the insurance company or whether the insurance company is just the manager for the employer’s policy.

🌸 In my case my work was a self-funded policy that was managed by a big name insurance company. Sometimes this can work to your advantage. If you are friends with the right people at work you can have HR or whomever have words with the managing company and have your claim approved right away. The place I worked was too big for me to successfully pull this off. In fact my place was so huge it took a month to get in touch with the right person so that I could get a copy of the legal version of the insurance policy.

🌸 Write a letter to the insurance company requesting all documentation of your claim including why they rejected your claim. You have a right to these documents under ERISA law and I copied and pasted the law into my request letter. While they didn’t send me everything I requested I did get a lot of documents that helped me assemble my appeal. By the way, there is a fine that can be imposed upon the insurance company for not producing these documents but that wouldn’t come until the court case level of appeal. Feel free to use the following text:

“Please mail me the following documents:

All documents used to decide the claim.

All documents rejected to decide the claim (clearly marked)

The clinical criterion used to decide the claim.”


After Approval

🌸 When I came up for review, I sent them all my medical notes from the date of application to the current date. I did this for both Social Security and LTD. In both cases, they continued my coverage without further review or a visit to their doctor for evaluation.


Learn More

🌸 Here is a website that I found incredibly helpful: http://www.masscfids.org/disability

🌸 Sleepy Girl Tips on How to Apply for Disability through Your Employer

🌸 Dahlia also appealed and won her LTD for Chronic Fatigue Syndrome How Dahlia Appealed (and won!) Her LTD Case

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