Reliance Standard Life Insurance Co

February 9, 2016Dear *** ***:We are in receipt of the complaint filed by the customer named in the Revdex.com Complaint ID noted above.The above-mentioned policy is a voluntary group disability plan that provides weeks of Short Term Disability benefits at a rate of 60% of an eligible employee's
salary.In adjudicating this claim, we needed to determine whether the customers injuries were work related, which is an Exclusion of the planIn addition, we had to determine if the customer's claim was subject to the policy’s Pre-existing Limitation.This policy provides benefits to a covered employee who incurs a period of disability caused by an Injury or Sickness, as defined by the policyHowever, it excludes benefits for a period of disability caused by a Sickness, which is covered by a Workers Compensation Act, or other workers disability law; or Injury, which occurs out of or in the course of work for wage or profitPlease refer to Exclusion provision on page of the policy, which is enclosed.According to information provided on the claim application, the customer indicates that while working for Chattanooga Kidney Center on June 29, 2015, she was injured after “bending over and putting acid in a wall”Information provided on the Attending Physician Statement, which was completed by DrDayle Hawthorne, indicates that “it’s possible that the claimant’s injury was work related or constantly aggravated by work”.In addition to reviewing the medical information to determine the causal connection of the injury to the customer's job, we must also determine if the customer's claim is subject to the policy’s Pre-existing Limitation.The policy explains the Pre-existing Conditions Limitation as follows:PRE-EXISTING CONDITIONS: An Insured will be considered to have a Pre-existing Condition and will be subject to the Pre-existing Conditions Limitation if:(1) the disability begins in the first twelve (12) months after the Insured's effective date; and(2) he/she has received medical Treatment, consultation, care or services, including diagnostic procedures, or took prescribed drugs or medicines for the Sickness or Injury, whether specifically diagnosed or not, causing such disability, during the three (3) months immediately prior to the Insured's effective date of insurance.Weekly Income Benefits will not be paid for a disability:(1) caused by; (2) contributed to by; or (3) resulting froma Pre-existing Condition unless the Insured has been Actively at Work for one (1) full day following the end of twelve (12) consecutive months from the Insured's effective date of insurance.According to the claim information, the customer was hired on November 25, and her insurance under this plan became effective on January 1, Since the customers insurance was in effect for less than months as of the date of her disability, the policy requires that we conduct a Pre-existing investigation to determine if the customer received medical treatment, care or services including diagnostic procedures, or took prescribed drugs or medicines for the Sickness or Injury, whether specifically diagnosed or not, causing such disability, during the three (3) months immediately prior to the Insured's effective date of insurance.Our records indicate this claim was received on October 26, On November 3, 2015, the claims examiner sent a request to the policyholder for the customer's enrollment form and payroll recordsThe requested information was received in our office on November 9, On November 9, 2015, the examiner sent the Pre-existing Investigation letter to the customer, which explains the policy provision as well as a Pre-existing Questionnaire that the customer is to completeIn addition, on November 9, 2015, the examiner sent a request to the attending physician for their medical records.Medical records were received from the attending physician on November 16, 2015.On December 21, 2015, the customer's completed Pre-existing Conditions questionnaire was receivedThe questionnaire identified several providers that she consulted with during the Pre-existing investigative period of October 1, to January 1, The physician listed on the questionnaire is the physician that completed the disability paperworkThe customer provided incomplete information regarding her health insurance carrier.On December 28, 2015, the examiner called and left a message for the customer to provide the mailing address for her health insuranceThe customer called back and provided this information on December 29, A request for the health insurance records was subsequently mailed to the provider on December 29, An initial follow up letter was mailed to the carrier on January 13, and a second and final follow up letter was mailed to the carrier on February 3, On February 9, 2016, our office received a response from the customer’s health insurance carrier.The customer was copied on all correspondence that has been mailed in regards to this claim.The customer states in her complaint that we are not investigating and gathering the necessary information to approve her benefitsShe believes we are stalling and not sending benefits to which she purchasedAs noted in the Pre-existing Investigation letter, due to the nature of this investigation and our need to gather additional medical records, the review of the file may require more time than usualHowever, we will strive to complete this investigation as quickly as possible with the customer’s continued cooperation.Our review of the claim file reveals that we have requested documentation to satisfy the policy’s requirements of eligibility, workers’ compensation as well as Pre-existing conditionsThe customer has received copies of all of our requests and has been in communication with the claim’s examiner and our Customer Care departmentWhile we understand that the customer has gone without funds for some time and this has caused her financial stress, we have adjudicated this claim in accordance with the Short Term Disability contract.Based on our review of the available medical records, it does not appear that the customer received treatment for her disabling condition during the Pre-existing investigation period of October 1, to January 1, However, the medical records reveal that the customer's injuries appear to be work related in nature, Which is an Exclusion of the contractThe records document that due to constant and severe pain, the customer is unable to function and she relates the problem to an incident that occurred on June 29, 2015; as well as repetitive work in different jobs in the dialysis center at her place of employmentTherefore, since her injuries occurred out of or in the course and scope of her employment, benefits are not payable under this Short Term Disability policy.Please be advised that this policy Exclusion, applies regardless of whether or not the customer receives workers’ compensation benefits.Although the customer is not eligible for benefits under the Short Term Disability policy, she is eligible to apply for benefits under her employer's Long Term DisabilityWe are currently in the process of establishing a Long Term Disability claim in our system for the customer.If you have any additional questions or concerns, please feel free to contact me directly at (*** *** ***.Sincerely,

? We are in receipt of your letter dated August 7, 2015, which was received in our office on August 12, Your inquiry has been forwarded to my attention for a response.In her complaint, Ms*** states that she underwent surgery on June 6, She filed her claim on May 21, and has
yet to receive a paymentShe states that her doctor’s office advised her that we repeatedly filed the incorrect papers to the wrong doctor’s office, with the incorrect doctor names for pulling her recordsShe was also informed that the papers that were submitted were not filled out in their entiretyMs*** states that she returned to work early because she could not afford to be without pay any longerShe is concerned that her early return to work threatens her surgery and that she is jeopardy of losing her property because of nonpayment.The group policy under which Ms*** in insured states, in relevant partPRE-EXISTING CONDITIONS: An Insured will be considered to have a Pre-existing Condition and will be subject to the Pre-existing Conditions Limitation if(1) the disability begins in the first twelve (12) months after the Insured's effective date; and(2) an Insured was diagnosed or treated by a legally qualified Physician with consultation, advice or Treatment occurring during the three (3) months immediately prior to the Insured's effective date of insurance.Weekly Income Benefits will not be paid for a disability:(1) caused by or (2) resulting from? a Pre-existing Condition unless the Insured has been Actively at Workfor one (1) full day following the end of twelve (12) consecutive months from the Insured's effective date of insitrance.We received Ms***’ claim on May 14, Upon our initial review of her claim, it became evident that we needed to conduct a pre-existing condition investigationMs***’ claimed date of disability was April 22, and the effective date of her insurance was July 1, As her claimed date of disability is within the first months from her effective date of insurance, we need to determine if she was diagnosed or treated by a legally qualified physician with consultation, advise or treatment occurring during the time period of April 1, to July 1, (the three months immediately prior to her effective date of insurance), for a condition that caused or resulted in her disability.It should be noted that a pre-existing condition investigation is sometimes a lengthy processThere are a number of variables that could affect the amount of time that the review takes, including, but not limited to, the number of providers that treated the claimant during the three months prior to the insurance effective date, and the length of time that it takes for the providers to send the records to usThe following summary of the timeline of events will show that in the case of Ms***’ claim, any delays in processing are due to the length of time that it has taken her treating physicians to provide the requested documentation to us.On May 19, 2015, we sent Ms*** a letter explaining our need to conduct the pre-existing condition investigation, along with a form (Pre-Existing Condition Questionnaire) which asked her to provide the contact information for any physician, hospital, and/or pharmacy that would have treated her for any condition for the time period of April 1, to July 1, On the same date, we sent a request for all medical records from April 1, to present to DrW*** D***, the physician who completed the disability claim form.We received the completed Pre-Existing Condition Questionnaire from Ms*** on May 26, On May 27, 2015, we sent requests for records for April 1, to present to DrW*** C*** and DrAllen W***On June 4, 2015, as we had yet to receive a response from DrD***, we sent a second request to his officeOn June 8, 2015, we received a response from DrD***’s office (*** *** *** ***) advising that the Reliance Standard Authorization for Use in Obtaining Information form that Ms*** completed to release records to us was not acceptable to their office because the authorization was not datedThe claims Examiner, Courtney H***, called Ms*** on that same date and advised her of the response from DrD***’s officeMs*** stated that she still had a copy of the authorization and would date it and return it to our officeWe received the dated? authorization on June 9, and sent it to DrD***’s office.On June 11, 2015, we had still not received a response from DrC*** or DrW***As such, we sent second requests to their officesOn June 17, 2015, we received a response from DrC***’s office stating, “Dr W*** C*** has not seen this patient since 2014.” However, on the same date, we received an invoice from Healthport, the medical records copying service for DrC***’s office, for pages of recordsWe sent payment to Healthport for the recordsOn June 18, 2015, MsH*** called DrC***'s office and advised that we were in receipt of their response, but our request did in fact as for all records from April of to presentThe representative at DrC***’s office asked us to send the request to them againQuite strangely, we received another response from DrC***’s office on June 22, stating, “This is not the correct provider, please check your records.”We received an invoice from Healhport for DrD***’s records on June 25, and sent payment to them on June 26, 2015.We received a response from DrW***’s office on July 1, stating that the authorization that Mrs*** completed must be datedWe sent a new request to DrW*** with the signed authorization on July 2, 2015.We received the records from DrC*** on July 6, 2015.We received the records from DrD*** on July 14, 2015.On July 17, 2015, we received an invoice from Healthport for the records from DrW***’ officeWe sent payment on that same dateOn August 3, 2015, we still had yet to receive the records from DrW*** (the last set of records needed to complete our review), so MsH*** sent an email to Healthport inquiring of the status.The records from DrW***' office were received on August 4, 2015, but only included records from April of to presentMsH*** called Healthport on that date and advised the representative that we had requested records from April of but had only received records from The representative advised that he would put in the request for the missing recordsMsH*** asked if it could be rushed, as it had been over two months since our initial requestMsH*** called Ms*** on the same date and explained the situationOn August 5, 2015, Ms*** called MsH*** and advised her that she called Healthport and they would be sending another invoice for the missing records and that they would not expedite the sending of the recordsWe received and paid this invoice on August 5, 2015.We received e-mail correspondence from Healthport on August 11, advising that a message has been sent to the field rep to review and scan the missing records as soon as possibleThe representative stated that we should allow 7-business days for the request to be completedOn August 23, 2015, Ms*** called MsH*** and stated that she contacted Healthport, who advised that the records were mailed to us three days agoAs of the date of this letter, the records have not been received.In her complaint, Ms*** indicates her desired outcome as, “Resolving issues with claim and Pay claim as requestedHer desired settlement is, “Finish the Job.” As explained above, we cannot make the determination of Ms***’s claim until all of the requested documentation is received and reviewedAs soon as the records from DrW*** are received, Ms***’ entire claim file will be reviewed by our medical departmentThis review should take 24-business hoursWe will communicate our decision as soon as we have made itPlease note that the possibility remains that Ms*** may not be entitled to benefits, should we determine that her disability was caused by or resulting from a Pre-Existing Condition, as defined in the policy.Sincerely,Todd D***, Supervisor Group Disability Claims Department

September 16, 2016Dear [redacted]:We are in receipt of the Revdex.com complaint filed on behalf of [redacted].To be eligible for benefits, the group policy requires that medical documentation must substantiate that an employee, while insured under the group policy, meets the group policy's definition
of disabilityThe group policy defines Disabled as follows:"Disabled" means the Insured is:(1) unable to do the material duties of his/her job; and (2) not engaged in any employment or occupation for which he/she is qualified by reason of education, training or experience and which provides him/her with substantially the same carning capacity prior to the start of the disability; and (3) under the regular care of a physician.[redacted]'s claim for Short Term Disability (STD) was received on July 26, According to the information received, the last day worked was June 20, and the claimed period of disability was June 23, due to pregnancyWe normally consider two (2) weeks prior to the estimated date of delivery when no complications are involvedThe medical information documented that the estimated date of delivery was July 9, 2016; [redacted] delivered via cesarean section on July 5, 2016.In order to evaluate [redacted]'s claim for consideration of disability benefits starting June 23, 2016, a request for medical records was faxed to her physician on July 28, A copy of the medical request letter was mailed to [redacted] on July 28, as wellThe requested medical records were received from her physician on August 4, 2016, The review was completed on August 8, and [redacted]'s claim was medically supported from the date of loss to the end of the postpartum period.The STD policy states the following:DAY BENEFITS BEGIN: Benefits, for one period of disability, will be paid as follows:INJURY AND SICKNESS: We will pay benefits from the greater of: (1) the fifteenth consecutive day of disability; or (2) the day immediately following the number of accumulated sick days applicable to the Insured.Following the completion of the elimination period, the STD benefit for the period July 7, to August 31, (end of the 8-week postpartum period) was issued on August 8, in the amount of $3,000.04.[redacted] contacted our office on August 23, to advise that she had not received the benefit check previously mailedWe advised that in order to void the check for reissue, our process required that she complete a Loss Check Affidavit (LCA), which includes authorization by a Notary RepublicOn September 7, 2016, [redacted] contacted our office to check the status of the replacement check, during this call she advised that the LCA was mailed back to our office on August 26, The LCA was received and scanned into her claim on September 7, The initial check was voided and the replacement check was reissued on September 8, The replacement benefit check was mailed to [redacted] via UPS overnight delivery and based on our system, the benefit check was received and has been cashed.STD benefits are paid to the end of the postpartum period when there are no complications that would preclude the claimant from returning to workWe have not been provided with medical documentation to support [redacted]'s inability to return to work beyond the postpartum period paid, August 31, As such, her claim for STD benefits has been closed as appropriate.If you require any additional information, please feel free to contact me directly at ###-###-####or via e-mail at [redacted]@rsli.com.Sincerely,Antoinette W.Supervisor, STD Claims Department

September 16, 2016Dear [redacted]:We are in receipt of the Revdex.com complaint filed on behalf of [redacted].To be eligible for benefits, the group policy requires that medical documentation must substantiate that an employee, while insured under the group policy, meets the group policy's definition...

of disability. The group policy defines Disabled as follows:"Disabled" means the Insured is:(1) unable to do the material duties of his/her job; and (2) not engaged in any employment or occupation for which he/she is qualified by reason of education, training or experience and which provides him/her with substantially the same carning capacity prior to the start of the disability; and (3) under the regular care of a physician.[redacted]'s claim for Short Term Disability (STD) was received on July 26, 2016. According to the information received, the last day worked was June 20, 2016 and the claimed period of disability was June 23, 2016 due to pregnancy. We normally consider two (2) weeks prior to the estimated date of delivery when no complications are involved. The medical information documented that the estimated date of delivery was July 9, 2016; [redacted] delivered via cesarean section on July 5, 2016.In order to evaluate [redacted]'s claim for consideration of disability benefits starting June 23, 2016, a request for medical records was faxed to her physician on July 28, 2016. A copy of the medical request letter was mailed to [redacted] on July 28, 2016 as well. The requested medical records were received from her physician on August 4, 2016, The review was completed on August 8, 2016 and [redacted]'s claim was medically supported from the date of loss to the end of the postpartum period.The STD policy states the following:DAY BENEFITS BEGIN: Benefits, for one period of disability, will be paid as follows:INJURY AND SICKNESS: We will pay benefits from the greater of: (1) the fifteenth consecutive day of disability; or (2) the day immediately following the number of accumulated sick days applicable to the Insured.Following the completion of the elimination period, the STD benefit for the period July 7, 2016 to August 31, 2016 (end of the 8-week postpartum period) was issued on August 8, 2016 in the amount of $3,000.04.[redacted] contacted our office on August 23, 2016 to advise that she had not received the benefit check previously mailed. We advised that in order to void the check for reissue, our process required that she complete a Loss Check Affidavit (LCA), which includes authorization by a Notary Republic. On September 7, 2016, [redacted] contacted our office to check the status of the replacement check, during this call she advised that the LCA was mailed back to our office on August 26, 2016. The LCA was received and scanned into her claim on September 7, 2016. The initial check was voided and the replacement check was reissued on September 8, 2016. The replacement benefit check was mailed to [redacted] via UPS overnight delivery and based on our system, the benefit check was received and has been cashed.STD benefits are paid to the end of the postpartum period when there are no complications that would preclude the claimant from returning to work. We have not been provided with medical documentation to support [redacted]'s inability to return to work beyond the normal postpartum period paid, August 31, 2016. As such, her claim for STD benefits has been closed as appropriate.If you require any additional information, please feel free to contact me directly at ###-###-####or via e-mail at [redacted]@rsli.com.Sincerely,Antoinette W.Supervisor, STD Claims Department

May 2, 2017Dear [redacted]:The above-mentioned policy is a self-administered plan, whereby Reliance Standard Life Insurance Company (RSL) provides administrative services, for a certain self-funded disability plan or self-insured salary continuance plan established by the Employer (the "Plan")The
Employer desires that RSL, assess and process all eligible disability claims, submitted by employees under the PlanAs the Administrator we have agreed to provide the Employer with assistance and advice in the review, assessment and processing of disability claims received by Employer under the Plan.The Employer shall be the [redacted] Claim Review Fiduciary ("Fiduciary) under the Plan for the benefit of eligible employeesThe Employer as Fiduciary has the discretion and authority to interpret the Plan and to adjudicate claimsEmployer agrees that all final decisions regarding payment or denial of claims under the Plan are Employers, and Administrator's (RSL) only responsibility is to provide requested review of such claims.The customer's Short Term Disability claim was submitted to RSL for review on February 23, RSL provided written advice to [redacted]on March 6, indicating that the claim was medically supported to receive disability benefits to March 24, An acknowledgment letter was sent to the customer on March 6, advising that the claim was medically supported to March 24, and that in order to support the customer's disability beyond March 24, 2017, additional medical information would be required.A request for medical records was faxed to the customer's physician on March 16, A follow up request was sent on April 22, 2017.To date, we have not received any additional medical records to evaluate the customer's claim for the approval of ongoing disability benefit paymentsUpon receipt of updated medical records, the claim will be reviewed for consideration of ongoing benefit payments.If additional information is required, please feel free to contact me directly at ###-###-####.Sincerely,Cheryl J., Supervisor Group Integrated Disability Claims Department

January 30, 2017Dear [redacted]:We are in receipt of the complaint addressed in the above referenced claim number.The above referenced policy is a voluntary group disability policy that provides weekly benefits following the greater of the fifteenth consecutive day of disability or the day
immediately following the number of accumulated sick days applicable to the Insured.In adjudicating this claim, we took into consideration the applicable policy provisions and medical documentation submitted by the customer's physicianOur determination on whether or not the customer meets the group policy's definition of disability will be based on the medical evidence in the claim file.Our records indicate that this claim was received December 1, as an incomplete claimThe claim application included the Employer Statement and the Attending Physician Statement but did not include the signed Employee StatementIn addition, the employer section was missing pertinent information that is required to process the claimA request was mailed and faxed to the policyholder on December 6, requesting the Employee Statement, the customer's payroll information and verification of the customer's last date workedOn December 20, 2016, the customer's claim application was received in our officePayroll records were received in our office on December 22, 2016.According to the claim information, the customer last worked November 25, The employer documented on the application that the customer received sick leave pay beginning November 28, to December 15, In addition, the physician documented on the Attending Physician Statement that the customer was disabled from work beginning November 28, to December 15, 2016.On December 31, 2016, a call was placed to the customer to discuss the claim and to obtain her complete mailing address, however the customer was not availableOn January 3, 2017, our office spoke with the customer and discussed the claim and benefit payment as it applies to the policyThe customer was made aware that benefits do not begin until the exhaustion of her accumulated sick days, which the employer indicated ended on December 15, It was also noted that the Attending Physician documented that the claimant would be able to return to work on December 15, 2016.In addition, it was explained that since the customer was paid sick leave benefits for the entire duration that the physician recommended, we would require medical records from the treating physician to extend benefits beyond December 15, 2016.A letter was sent to the customer on January 3, advising that should her disability extend beyond the estimated return to work date, we would require medical records from November to the present date.In the complaint, the customer advised that she was not informed of what would be required to pay benefitsOur records indicate that the customer was made aware of what was required during the January 3, telephone call as well as in the January 3, letter.A check in the amount of $was processed on January 25, 2017, for the period of December 16, to January 9, in the amount of $Medical records will be required to support ongoing disability beyond January 9, 2017.If you have any additional questions or concerns, please feel free to contact me directly at ###-###-####.Sincerely,Cheryl J., Supervisor Group Integrated Disability Claims Department

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me.? Thank you for helping me out in this and ensuring that the company actually keep their word when they said they would reimburse my costs
Regards,
[redacted]

April 12, 2016Our Policy # [redacted]Dear [redacted]:In reference to the complaint listed above we have sent [redacted] his refund check in the amount of $194.59. Enclosed is a copy of the refund check for your information.If you have any questions or need additional information, please feel free to contact us.Sincerely,Diane B

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me.  I would like to add that the medical records requested by Reliance still had not yet been received on my end for me to forward to them prior to receiving my check.  I received my payment prior to them receiving the documents requested.  
Regards,
[redacted]

April 1, 2016Dear Sir or Madam:We are writing to acknowledge receipt of the above-mentioned correspondence. We have forwarded this complaint to the following department for handling:NAME: George R[redacted] TITLE: Manager DEPARTMENT: Premium Billing and Collection[redacted]We are presently looking into...

this matter and you will be hearing from us shortly.Please note! If at any time you correspond directly with the individual listed above, it would be appreciated if a copy of that correspondence were sent to me as well, so that we can track all correspondence and ensure that timely responses are provided to you.Sincerely,Denise B.

January 30, 2017Dear [redacted]:We are in receipt of the complaint addressed in the above referenced claim number.The above referenced policy is a voluntary group disability policy that provides weekly benefits following the greater of the fifteenth consecutive day of disability or the day...

immediately following the number of accumulated sick days applicable to the Insured.In adjudicating this claim, we took into consideration the applicable policy provisions and medical documentation submitted by the customer's physician. Our determination on whether or not the customer meets the group policy's definition of disability will be based on the medical evidence in the claim file.Our records indicate that this claim was received December 1, 2016 as an incomplete claim. The claim application included the Employer Statement and the Attending Physician Statement but did not include the signed Employee Statement. In addition, the employer section was missing pertinent information that is required to process the claim. A request was mailed and faxed to the policyholder on December 6, 2016 requesting the Employee Statement, the customer's payroll information and verification of the customer's last date worked. On December 20, 2016, the customer's claim application was received in our office. Payroll records were received in our office on December 22, 2016.According to the claim information, the customer last worked November 25, 2016. The employer documented on the application that the customer received sick leave pay beginning November 28, 2016 to December 15, 2016. In addition, the physician documented on the Attending Physician Statement that the customer was disabled from work beginning November 28, 2016 to December 15, 2016.On December 31, 2016, a call was placed to the customer to discuss the claim and to obtain her complete mailing address, however the customer was not available. On January 3, 2017, our office spoke with the customer and discussed the claim and benefit payment as it applies to the policy. The customer was made aware that benefits do not begin until the exhaustion of her accumulated sick days, which the employer indicated ended on December 15, 2016. It was also noted that the Attending Physician documented that the claimant would be able to return to work on December 15, 2016.In addition, it was explained that since the customer was paid sick leave benefits for the entire duration that the physician recommended, we would require medical records from the treating physician to extend benefits beyond December 15, 2016.A letter was sent to the customer on January 3, 2017 advising that should her disability extend beyond the estimated return to work date, we would require medical records from November 2016 to the present date.In the complaint, the customer advised that she was not informed of what would be required to pay benefits. Our records indicate that the customer was made aware of what was required during the January 3, 2017 telephone call as well as in the January 3, 2017 letter.A check in the amount of $685.71 was processed on January 25, 2017, for the period of December 16, 2016 to January 9, 2017 in the amount of $685.71. Medical records will be required to support ongoing disability beyond January 9, 2017.If you have any additional questions or concerns, please feel free to contact me directly at ###-###-####.Sincerely,Cheryl J., Supervisor Group Integrated Disability Claims Department