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Lakeshore - [cancer] One example of the weird things sick people have to deal with
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Jay Lake
Date: 2013-01-19 05:41
Subject: [cancer] One example of the weird things sick people have to deal with
Security: Public
Tags:business, cancer, health, personal, weird, work
Our system is so strange, and so unkind to the seriously ill. Insurance and benefit processes are optimized to mitigate fraud, not to help people in need. That means real people in real, desperate need have to jump through sometimes bizarre hoops to achieve compliance. This at a time in their lives when they are least equipped to deal with bullshit. As I've said before, I wonder if it would be cheaper to remove all the complex infrastructure of compliance enforcement and fraud management and just accept a percentage of free-riding scammers in any given benefit program. Basically, shift the overhead to kinder place. Not that we'll ever do that, because of the apparently horrible thought that someone, somewhere, might be enjoying an unearned benefit at our expense. As a society, we value punishing the non-compliant far, far above the value we place on actually helping people in worst need of their lives.

Sobeit. That's the system we live under. During the 43 years I enjoyed the privilege of good health, I didn't question it either. I don't really expect healthy people to question it now. Once you need the system, it's a bit late to start protesting. Frankly, none of us seriously ill people have the time and energy to do so. We're too exhausted trapped in our conditions, and too busy dealing with the Byzantine healthcare and benefits systems. Meanwhile, very few of you healthy people are even aware of the need to do so.

So here's the latest wheeze: Disability benefits.

Like most people with a white collar job, I have coverage for both short term disability (STD — Yes, I know. Quit giggling in the back.) and long term disability (LTD). STD is a benefit my employer provides, LTD is an elective benefit that I pay for with a little dip into every paycheck.

As it happens, determining what qualifies as a disability under either coverage umbrella is a pretty strange process. STD isn't quite as weird as LTD, but it has its quirks. The rules are complex and contradictory, and require cross-referencing different systems and rulesets written to differing standards. In LTD, for example, the question of whether I qualify under the rules of the Social Security Administration (SSA) affects whether or not I will qualify under my private, employer-sponsored, self-paid plan. Likewise, the precise information my physician provides to my health insurance carrier can make a significant difference.

I'm not seeking LTD yet. I don't need it right now. But I am trying to understand the process so that if and when my cancer goes terminal, or if I reach a point where I will likely be in continuous treatment for the rest of my life — either or both of these things are probable in the next year or so — I'd like to know what to do. STD applies to my forthcoming surgery leave, albeit with some weird conditions.

Something cropped up yesterday in the LTD discussion that struck me as especially strange. (My Dad has been researching a lot of this for me. As a retired senior Federal bureaucrat who's managed some very large budgets under Federal accounting rules, as well as living under the strict requirements of high level security clearances for almost four decades, he's quite good at sorting out paperwork and rules.) As it happens, I hold a small LTD plan as a rollover benefit from a job I left over a decade ago. I pay a modest quarterly premium, and the plan will provide me with a modest supplementary income should I ever claim LTD status. Their criteria are, of course, different from that of the SSA or my employer-sponsored plan.

Yesterday, the payroll department at my Day Jobbe informed me that according to the rules of my employer-sponsored LTD plan, any income from other LTD sources, including SSA or my privately-paid LTD plan, will be deducted from my employer-sponsored LTD benefit.

What? The? Hell?

I pointed out that this was both illogical and punitive, and asked what the reasoning was. The response I received was sympathetic but unhelpful. Basically, they don't know, and they also find it weird. To be clear, my employer has been fantastically supportive through these past five years, both in terms of corporate policy and in terms of my individual managers and co-workers. I am very lucky to work where I do. They are not creating this problem in any direct sense. I told payroll I would be consulting an attorney, and they asked me to please share whatever opinion I received with them.

Here's what I see as the problem in this case. If I'm wise and foresighted enough to have a separate LTD benefit paid for privately, what does that have to do with the insurance plan that would pay out my LTD claim? Presumably their premium rates and actuarial calculations are geared toward paying full benefit. My secondary, private plan is essentially income supplementation, as the employer-sponsored LTD pays out at 66-2/3% of my income level. So because I was smart enough to buy "gap" insurance against the possible income loss, now I am to be punished by having the amount of that "gap" benefit deducted to cap me at 66-2/3%? What possible justification is there for this? How is this even legal?

Note that health insurance carriers do something similar, but it's logical enough. They're trying to avoid double paying claims. That makes sense to me. But health insurance plans don't work on a defined benefit basis. They're at-need, and they're paying for that need. With two carriers covering the same patient, they can negotiate amongst themselves as to which carrier will pay what percentage of which needs.

LTD benefits are defined — in my case, 66-2/3% of base salary. Income from other sources is irrelevant to that benefit definition. This would be like your 401(k) provider deducting any other income from your retirement account payout. The LTD benefit is defined, and paid for according to a specific schedule.

I have not yet been able to speak to an attorney. I suspect the answer I'm going to ultimately receive is that this is somehow written into Federal law. This is still an illogical and punitive step on the part of my LTD provider which makes no sense to me. If nothing else, I may as well quit paying the premiums for my private LTD plan, as it is literally useless to me in light of these rules from my employer-sponsored LTD plan.

So, one more example of the kind of weird things sick people have to deal with. While sick and unable to cope with the bizarre details. I'm lucky I have my Dad in the loop, because I can't imagine how I'd be fielding this all by myself along with everything else.

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Beth
User: casacorona
Date: 2013-01-19 14:05 (UTC)
Subject: (no subject)
The hoops that ill and disabled people have to jump through are outrageous. The system is designed to make it very difficult to force the for-profit insurance industry pay out one cent of their hoard.

But on the other hand, there are insurance scammers. Not just the odd individual -- if it were individuals, I'd say let it go -- but organized private for-profit medical "suppliers" who are in the business of scamming medicare and private insurance. They double and triple bill for services and equipment that they haven't provided. They bill for fictitious patients. They bill for dead patients. It's a billion-dollar business. The federal hoops are designed to weed them out. One example is this: Columbia/HCA http://www.wusf.usf.edu/news/2010/06/18/whistleblowers_say_rick_scott_knew_about_medicare_fraud

There are many more. I got caught up in one during my knee surgeries, when the supply house that rented my rehab equipment started billing the insurance for thousands of dollars worth of stuff I didn't have.

Doesn't help in your situation, I know. But it's not entirely about making it hard for sick people to get help. It's the American idea that medicine is a great way to make a killing.
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Keikaimalu
User: keikaimalu
Date: 2013-01-19 15:45 (UTC)
Subject: (no subject)
Sorry to hear all this, Jay. It sucks.

FWIW, I have a friend who used to be a disability case manager for a governmental agency (not sure which one). If you want to chat with her sometime, just let me know. She's very helpful.
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threeoutside
User: threeoutside
Date: 2013-01-19 15:47 (UTC)
Subject: (no subject)
I'm so sorry you have to go through this shit (at all), and I agree it's a total outrage. At some point in the past this country decided (apparently) to discard all other human values and adopt only one: Profit. It's the kind of thing that makes this atheist *wish* there was a Hell because it would be populated with an awful lot of insurance execs, attorneys and legislators. Oh, and I can't forget fundie evangelists, but that's a different rant.

As for what people without someone like your dad do - easy. They suffer, they die, and in the meantime the insurance companies, medical establishment and drug/machinery vendors sop up every penny that's overlooked due to their Byzantine "information" shell games. But that's okay, because Profit.
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Keikaimalu
User: keikaimalu
Date: 2013-01-19 17:30 (UTC)
Subject: (no subject)
This.
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scarlettina: Good God
User: scarlettina
Date: 2013-01-19 16:03 (UTC)
Subject: (no subject)
Keyword:Good God
I'm so sorry to hear about this, Jay. I completely sympathize. But I also have to admit that I'm not surprised by it at all. You know my history: my dad died when I was 11, my mom when I was 19. This made my brother and I eligible to receive my father's social security benefits until I was 21--which were just enough to cover the mortgage on my parents' house so we didn't have to move right away. But the catch was that if I received any income over and above that, I'd have to pay back whatever the overage was. You can bet that it felt like we were being punished for trying to survive. It was insane and miserable. And this pattern seems to be the template that many kinds of benefits follow. Yes, it's intended to help but, yes, it's also intended to prevent fraud and I think you're right: there's so much focus on preventing fraud that the idea of helping those in need gets lost along the way. And, of course, it makes me wonder how and why all those strictures that make it difficult to receive a benefit got put into place, and who made sure they were there. I have thoughts, but they would be speculation--and probably unfair speculation at that. But at bottom, you're right: the fraud prevention system makes benefiting from the social safety net almost as stressful as the trauma that qualifies one to receive the benefit in the first place.
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e_bourne
User: e_bourne
Date: 2013-01-19 16:15 (UTC)
Subject: (no subject)
Dealing with all of this kind of thing is an egregious insult to people who really need help. We investigated LTD for Mark, since it was clear he would not be able to work (at least on a full time basis) and decided the pain and suffering of going through the hoops was not worth it -- which I know we were enormously fortunate to be able to afford to say that. Many people in our position would not have been so lucky.

The rules on your LTD policy are written in the policy. There are LTD and STD policies that do not have a deduction in them (my AFLAC STD and LTD, for example, do not deduct for additional income). Many insurance policies, however do.

Companies buy the insurance policy that best suits their corporate needs, not yours. The one exception can be S corps where the owners are employees. Owners want good protection just like everyone else. In that circumstance, what they want everyone else gets as well.

All that being said, 66% of your salary seems unusually harsh -- a lot of policies will allow you supplemental income up to 80% of your salary before they start deducting. You might want to double check that. Also, if you have any term life insurance, you should be able to cash out the policy at the point you go on LTD -- and that is NOT supplemental income.

I am so very sorry that you have to deal with this -- that anyone does as they are dealing with serious illness.
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martianmooncrab
User: martianmooncrab
Date: 2013-01-19 17:53 (UTC)
Subject: (no subject)
Kudos to your Dad, its such a maze of rules that you would swear that ex lab monkeys on crack came up with them.

The ones we stuck electrodes into.
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joycemocha
User: joycemocha
Date: 2013-01-19 18:46 (UTC)
Subject: (no subject)
Sigh. Yeah. The portability plan issues we're going through with the son are interesting...and relatively mild so far because of who we're dealing with.

So far.

I'm glad you've got your father to help. There's a reason that the Insurance class was the one I got the lowest grade in back when I was getting my legal assistant certificate...and that was back in the 80s. Insurance law is the most Byzantine set of bureaucratic stuff I've ever seen....
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Clint Harris
User: wendigomountain
Date: 2013-01-19 18:50 (UTC)
Subject: (no subject)
I ran into a similar thing years ago with Unemployment insurance. They paid around 2/3 of what I had made at the job that fired me, which was very, very hard to live on. If I got ANY additional income, my UI would be adjusted so that I wound up making roughly the same, if not less. How is this encouraging anyone to get into the workforce? If I can sit at home and apply for jobs at NASA I'm not qualified for all week (and play Call of Duty add day), rather than get a part time job at Subway and not be able to make rent, where is the logic in any of this?
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Karen
User: klwilliams
Date: 2013-01-21 04:55 (UTC)
Subject: (no subject)
The plus side to this is that you can't get dinged for *not* getting a job at Subway or for turning down a job offer at Subway (assuming you didn't get laid off from fast food).
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shelly_rae
User: shelly_rae
Date: 2013-01-19 19:08 (UTC)
Subject: (no subject)
I've made use of STD and LTD several times and each time it seemed like they were pestering me--well pestering my care takers since I was completely out if it for some of that. I also was forced to going to extra doctor appointments to prove that I couldn't work and to swear that I wasn't receiving incomes from other sources.

Now I'm on meds that are restricted. So I must go to the doctor every month to get a script and then the insurance company will only allow it to be filled in a certain manner (probably like the meds you talked about). But if I forget? A common problem for someone with tbi, they will never fill or allow me a few to get by. Cause you know, I might be making extra money by selling the med I need to function. Really? </p>

This is my biggest challenge for leaving the country for a month. Meds, how to get them and how to get enough for the trip. Fortunately my doctor is on my side. Unfortunately my insurance company is not.

I've always been impressed with how you've managed to keep working steadily through all this. Healthy people take more sick days than you do.
Good luck.
Anon

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Lethran: Angel
User: gwyd
Date: 2013-01-20 03:48 (UTC)
Subject: (no subject)
Keyword:Angel
I just wanted to give you a heads up that LTD with the Feds takes 2-4 years to kick in after filing. If you win your case to get them, they give you the back benefits, but it takes that long. If you do plan to file, get a professional to do your paper work. The system is designed so that the more disabled you are the harder it is to get through the paperwork labyrinth and knowing how exactly to phrase things is crucial to succeeding. You need a specialist in disability law if you want even a chance at getting your benefits.

I'm with you all the way on how fucked up the system is.
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Amanda
User: cissa
Date: 2013-01-23 01:25 (UTC)
Subject: (no subject)
Yes, this.

When we needed to get Social Security disability for our mentally-ill daughter, they denied it the first couple of times- and we were lucky, because it "only" took 9 months to a year. (There was a lot of documentation.) We figured she needed it, because at that point it looked like she had a good chance for a long-term mental health stay, and we would have been ruined by that.

But yeah- plan to spend at least months dealing with complex and contradictory paperwork, and appealing a denial a few times.
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Oneself
User: snippy
Date: 2013-01-23 23:59 (UTC)
Subject: (no subject)
Not strictly true, there is a short list of disabilities that receive immediate aid (for example, kidney failure-my friend got aid 2 months after applying), but generally true for most disabilities.
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Karen
User: klwilliams
Date: 2013-01-21 04:52 (UTC)
Subject: (no subject)
My previous company was purchased by a much larger one. The larger company has a LTD benefit similar to yours, that it will pay 2/3 of my salary if I become disabled. I think most big companies have something similar. I was laid off from my previous company rather than being moved over as part of the acquisition, I suspect because I'd been sick a lot the year before. One catch of this LTD benefit is that you cannot become disabled from a condition you had before joining the company (again, most companies have this catch). When did I get diagnosed with MS? The day after I was laid off from my previous company.
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Little and foxy and sexy... what more do you want?
User: little_foxy
Date: 2013-01-21 13:26 (UTC)
Subject: (no subject)
I have to say that from the other side of the pond, this stuns me.... I hope that you can sort out the maze that is the ridiculousness of this...

and I shall be thankful that I don't have to deal with a system even remotely like this....
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Amanda
User: cissa
Date: 2013-01-23 01:27 (UTC)
Subject: (no subject)
I read a number of years ago that at least 67% of the money that goes to help the needy actually goes to the middle-class gatekeepers that prevent the needy for accessing the services they need. I believe this.

Removing the gatekeeping function for the most part would be more cost-effective than the current system, where more and more money goes to the middle and upper classes.
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