Complaint / review text:
Firstly, I apologize for the longevity of this, but I think it's important to include these details in the hopes that others may be able to relate and hopefully respond in some way.
At the end of August 2005, I had to leave work due to panic disorder and anxiety; as of today (1/13/2006) I have not been back. My job as a Capital One call center supervisor is EXTREMELY stressful, and getting yelled at and cussed out for 10 hours a day just took its toll. I have a history of anxiety/panic disorder (it also runs in my family) but was fine when I worked in other lines of work. But by the time I left Capital One in August I was having 3-4 severe panic attacks every week. It was delibitating.
Since September 2005 I've been seeing a psychiatrist who specializes in panic disorder; he even wrote a book about it. I filed a short-term disability claim with Aetna on Sept 22, the day after my first appointment with the psychiatrist. It has been a complete nightmare dealing with Aetna ever since.
It started when Aetna automatically denied my claim because they didn't get any medical documentation supporting my claim within five business days of when I filed it. But that's because no one at Aetna (including my case handler, Susan Baker) ever TOLD me about this five-day deadline until AFTER it had already passed. That was the first of many errors, misinformation and miscommunications initiated by Aetna.
After my initial claim was denied due to this error, I decided that the only way to ensure my disability appeal would be approved would be to take it upon myself to get all the documentation and compile a comprehensive appeal. I'm a perfectionist anyway so of course I wanted to give Aetna as complete a picture of my disability as possible, in addition to providing them with plenty of medical evidence supporting my disability claim.
I wasn't really stable enough to do it all myself, though, so my mother helped me out immensely; she's had experience with insurance companies and other legal proceedings. Mom helped me figure out what documentation to obtain, how to write the appeal, etc. We sent about 30 emails back and forth to each other, plus multiple drafts of the appeal letter and discussions on what to include, not include, etc., working on it for about six weeks. We used the information Aetna provided in the initial denial letter as a guideline.
(I should note that during this period, my anxiety actually INCREASED and my panic attacks were not disappearing, despite being on three forms of medication. I was so worried that my appeal would be denied, which is why I dedicated so much time and energy to it, even though it was made more difficult by the stress it was causing me.)
On Dec 8th I finally finished the appeal and mailed it to Aetna via Priority Mail, certified/return receipt to 101 Yorkshire Blvd, Lexington KY, and it was signed for on delivery on Dec 12th. I received the receipt back in the mail three days later. PROOF that Aetna received my appeal. I called on Dec 15 to check on it and was told it still wasn't in the system, but that it WAS mailed to the correct address, and since I had proof that my appeal had been received, the 45-day decision period would begin on Dec 12. That meant I'd get a decision by Jan 25,2006.
On Monday, Jan 9,2006, I called again to check the status of my appeal. This time I called the Appeals Unit in Hartford (on the advice of the rep I talked to on Dec 15) and spoke with Bonnie. To my dismay and surprise I was told there was no record of it at all. And guess what? As far as Aetna is concerned, if they don't have a record of something, then it never happened even though I have proof of its receipt by a human being.
Furthermore, Bonnie explained to me that when a claim is denied because no paperwork is received by the five-day deadline, the claimant (me) is supposed to send the documentation in so my case handler (Susan Baker) in the Tampa office can review it. If upon reviewing the documentation Susan felt the initial denial could be reversed, then she would do so and I'd finally get my disability payments. If not, THEN the paperwork would be sent to the Appeals Unit in Hartford. This was contrary to EVERYTHING every other Aetna rep had told me.
On Bonnie's suggestion, I then called the Tampa office and was transferred to a supervisor, Deb Pernicano. Ms Pernicano asked me to fax the appeal to her, so she could forward it to case handler Susan Baker. I told her I didn't want to fax anything, because that was an even greater risk that pages of the appeal would be lost and/or illegible. Then she asked if I could email it to her, an option which I readily accepted.
Ms Pernicano said that because my claim hadn't been denied due to medical reasons, but because the documents just hadn't been received yet, her department should be able to review the documentation I sent within a few days and let me know if they can reverse the denial decision. If they couldn't, they'd have to forward it to the Appeals Unit.
Finally, after four months, a ray of hope. My mother and I had worked so hard on the appeal that I felt confident that upon receiving the documentation, they would reverse the denial decision. Not only that, but my psychiatrist said that he's never had a patient whose disability claim was denied due to medical reasons. So, I was finally feeling pretty good about this.
I emailed the documents to Deb Pernicano (supervisor) and Susan Baker (case handler) at 8.01amET Wednesday morning. At 9.15amET, Susan Baker left a phone message saying that she was NOT reversing the denial and that she was forwarding it to the Appeals Unit.
WHAT!?!? I couldn't believe it, and still can't. It made no sense. So I called her, because after four months I felt like I deserved a real answer. It went something like this:
ME: Hi, Susan. I'm returning your phone call about my appeal?
SUSAN: Oh, I was just telling you that I have decided not to reverse the denial and that I've forwarded it to the Appeals Unit.
ME: Really? Can I ask why you won't reverse the denial?
SUSAN: Well, I reviewed the documents you sent, and the most recent document from Dr K [psychiatrist] was from way back in September. It's too dated now.
ME: Forgive me, but that's not correct. He filled out the claim form in October, and provided me with an explanatory statement in late November. I included those in my email [a PDF attachment] — did those documents not come through properly?
SUSAN: Oh, yes, they came through, and I reviewed them. But I have still decided not to reverse the denial and I've forwarded it to the Appeals Unit.
ME: Well, I don't understand. If you received the documents and saw that they were completed more recently than September, I don't understand how that can be the basis for a denial.
SUSAN: I've based my decision on the information you provided. You'll have to take it up with the Appeals Unit now.
ME: I'm sorry, but I've been dealing with this for over four months now and would really like to know what's going on. I've sent you a lot of information to review. So please explain to me specifically WHY you are not reversing the denial.
SUSAN: [Pause] Well. After reviewing what you sent, it was evident to me that in order to create the appeal that you did, you would have to be able to concentrate, use judgement and make decisions, just like you would in order to perform your job at Capital One. So, based on what you submitted I don't believe you are actually disabled.
ME: [Scraping my chin off the floor.]
Listen up, fellow perfectionists, and take note: My appeal was denied NOT because the medical information provided didn't support my claim. My appeal was denied because I was TOO THOROUGH.
That's right, people! Someone who puts together a coherent and comprehensive appeal over 6 weeks with the constant help of her mother and other relatives couldn't POSSIBLY be disabled the way her doctor says she is even if he IS an expert on the subject!
All kidding aside, to discover that all my hard work to ensure the APPROVABILITY of my appeal was actually used as the basis for DENYING it made me feel like I was not just taking a step backwards, but like I was being shoved backwards. For someone who has always strived for excellence and to cross all my T's and dot all my I's, it's something I'm having a hard time comprehending.
On the flip side, however, if I had just submitted the bare minimum, with no cover letter or personal explanation of my medical history, etc., they probably would have denied it because there wasn't enough documentation. I'm afraid to submit MORE documentation because I don't want it to be used against me. It's a total catch-22. I CAN'T WIN.
I tried telling Ms Baker that I didn't compile the appeal overnight or even over a few days, but that I had been working on it for nearly two months before I originally submitted it in December. I also tried telling her that I had LOTS of help from various people, that there was no way I COULD do it on my own; I wasn't in the frame of mind to deal with all of it by myself.
Not only that, but there is a HUGE difference between being in my very stressful work environment and being in the safety and comfort of my home. OF COURSE I'm going to have a bit more concentration at home that's because I'm away from work and the things that trigger my panic attacks. That's why I haven't been back there since August 27,2005, not even to drop by and say hello to friends.
But it didn't matter. She couldn't care less. She just kept repeating herself like a robot.
It angers me that Susan Baker's denial reason is completely contrary to Aetna's stated basis for deciding the approvability of a disability claim: "Certification is based on the medical information provided."
Her denial reason has NOTHING to do with the medical information provided. It was a subjective decision made after skimming an 18-page appeal in an hour's time and determining that my appeal looked too well-prepared to be done by someone who is actually disabled.
Even worse is the fact that I learned later that Susan Baker did NOT note my file about the denial reason she'd given me over the phone. When I talked to the Appeals Unit rep handling my case now (Maria), I demanded that there be a written record of what I was told. I'm also going to submit a notarized statement swearing that what Susan Baker told me is the absolute truth, and demand that THAT also be added to the written record. I don't want her to get off the hook for this. She denied my claim improperly and unethically, and I'm not going to let that pass on by.
If you can relate to this or know about these sorts of aetna denials, please let me know!
I am looking for others who can help me figure out the best way to get this resolved. After 4 months with no income, I can't afford a lawyer, so my options are a bit limited. Both my psychiatrist and therapist have said they've EACH had DOZENS of patients from Capital One who seek treatment for work-related stress, anxiety and panic disorder. Privacy laws obviously prevent me from finding out who they are and seeing if they've had the same problems filing short-term disability claims with Aetna.
I have searched the internet for the past couple of days and have yet to find anyone whose claim has been wrongly denied because it was "too well-prepared". I'm no lawyer but it seems obvious to me that this denial reason I was provided is completely unethical. PLEASE HELP BY POSTING A REBUTTAL!
Thanks in advance for any guidance you can provide. If you're dealing with Aetna in the same unfortunate way that I am, best of luck to you.