Advice needed - Aetna then, now The Hartford

[howinus50]

Hi
My wife has been on LTD since 2015. Initially the LTD was administered by Aetna and now The Hartford. My wife has a severe mental illness(schizophrenia) which her company stated was NOT subject to the 24 month mental illness LTD limitation. This was confirmed in an email correspondence with the company's leave management specialist..She also has been on SSDI since 2015. Aetna did a full review in 2017 and determined that she is totally disabled and her LTD will continue.
The Hartford has administered the plan since 2017 and I received a call last week stating that her LTD should have ended after the 24 month mental health limitation and they will be seeking overpayment since 2015. Of course i was shocked and my wife is a nervous wreck . I probably will have to seek legal advice but I would greatly appreciate any suggestions on what to do.
thanks in advance

 

[scagnt83]

Have you sent Hartford the email you have from Aetna?

 

[howinus50]

HI
the email i received was actually from the company ( they are self insured) the LTD is just administered by the Hartford and previously Aetna. Yes I did send the email to the Hartford and haven.t received a response. Aetna had a full review and continued coverage. Now Hartford said they interpreted documentation incorrectly. Sounds awful fishy.
This is a very large company and if they are going after my wife for years of overpayment there are probably many others that they are doing this to

 

[scagnt83]

HI
the email i received was actually from the company ( they are self insured) the LTD is just administered by the Hartford and previously Aetna. Yes I did send the email to the Hartford and haven.t received a response. Aetna had a full review and continued coverage. Now Hartford said they interpreted documentation incorrectly. Sounds awful fishy.
This is a very large company and if they are going after my wife for years of overpayment there are probably many others that they are doing this to

Self insured LTD?? Interesting. Ive been in the benefits biz for 14 years and have never actually seen one in the field before that I know of. (very common for health insurance). I take it this is a large company...

This could also be coming from the company. If they felt Aetna was paying unqualified claims, they might have asked for a plan wide review. (and that could be the cause for change in admin)

On the flip side, being self insured, going to company management about this issue could possibly help the situation (assuming my previous statement is not true).

If you took all the proper steps as the customer, I doubt they would get any real traction "going after you" for the payments. It is up to the carrier to determine benefit eligibility. I've only heard about this when the carrier was purposely mislead by the client. Which is why I mentioned that the company could be pushing this.

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There is no way for us to determine if her condition qualified without actually seeing the policy document.

IF she qualified, based on your statement, her condition must have fallen under some type of Exclusion within the policy, or perhaps a Rider that was added. Because based on your statement alone, her benefits should have been cut off after 24 months.

 

[howinus50]

hi
Thank you for the reply. Yes it is a large company (FedEx Ground ) and the leave management specialists I mentioned are FedEx employees. I believe you are correct that FedEx Ground management is reviewing their LTD policies and seem to NOW say the exclusion or Rider she received ( which I specifically asked FedEx about after the 24 months was a mistake.
Supposedly, a Ground leave specialist told me they would contact The Hartford and see what can be done. The Hartford rep seemed a bit surprised that this is now an issue because many large companies have exclusions for schizophrenia in which is not subject to the 24 month limitation. What really floored me is when she hinted that the company would be seeking overpayment.
After initial approval in 2015 and a subsequent full review which stated LTD will continue in 2017 ( both by Aetna ) , its ridiculous that Fedex would now say an overpayment is due
I had trouble in 2015 receiving the full LTD documentation. All i had was a plan summary stating that mental health is subject to the 24 month limitation and that after the 24 month the employee would have to be seemed totally disabled for benefits to continue

 

[scagnt83]

Its good you have the letter still as documentation.

You need to request the "Plan Document" or "Master Policy" or "Plan Contract" or whatever term they use for the group contract. If there is an exclusion for the condition, it will be listed there. If she meets the conditions, things should be able to be cleared up.

Without the contract itself, you have no way to counter their claims. The letter helps, but it does not stipulate "why" her condition qualified under their definition of Total Disability. That is the big issue you have right now.

If you dont have the Plan Contract, you need to request it. FedEx should have this in the HR dept. and of course Hartford does as well. You are legally entitled to this contract. You could also ask HR for any enrollment related paperwork they might still have on file for her. There might be something in there that could be helpful.