Disability Claims for Idiopathic Hypersomnia – Part I

disability claims for idiopathic hypersomnia - part I

If you’re not already familiar with Idiopathic Hypersomnia, it is the rare sleep disorder from which I suffer. Read up on the disorder and many of the presenting symptoms in my previous post.

Related:

In my previous post, I had posted an excerpt of the appeal I submitted back in 2014 after having been declined twice for a short-term disability claim for 3 weeks. I had posted a link on a Facebook support group in the hopes that my ordeal, story and ultimate success in getting the disability claim approved would help others in the same predicament. The response was far beyond what I had ever imagined, so I decided that I should share the entire process so it could hopefully encourage and help others going through similar situations. Living with idiopathic hypersomnia is tough enough as it is – we don’t need the additional stress and burden of not being understood and having our medical claims denied because the case manager doesn’t know what they’re dealing with.

The below is Part I of my Short-Term Disability claim. It includes:

  1. The first letter from my family physician (for the first week)
  2. The second letter from my family physician (for the next two weeks)
  3. The Medical Report, as required by the benefits company responsible for disability payments (short term and long term)
  4. The first STD claim decision letter (denied)

Coming soon:

  • Disability claims for idiopathic hypersomnia – Part II
  • Disability claims for idiopathic hypersomnia – Part III

 


First letter from my family physician

I had first seen my family physician the week prior, but because of the condition I was in, I had somehow managed to lock my keys in my bedroom and missed nearly my entire appointment. I had reviewed my symptoms with my doctor and she had provided some quick suggestions but was unable to complete a full diagnosis. We rebooked another appointment for November 27th, at which time she took me off work for 1 week. The below is a copy of my doctor’s note.

November 27, 2013

To Whom it May Concern: 

Re: [Ulyana Frank, Date of Birth] Age: 25

Patient was seen in clinic today. Please excuse her from work duties until Dec 5, 2013. She will be reassessed on December 4, 2013.

Yours truly,

[Family Physician]


Second letter from my family physician

After a week off from work, I returned for a reassessment the day before I was supposed to return to work. Based on the symptoms, she took me off work for another 2 weeks, for a grand total of 3 weeks.

December 4, 2013

To Whom it May Concern:

Re: [Ulyana Frank, Date of Birth] Age: 25

Patient was seen in clinic today. Please excuse her from work duties until Dec 18, 2013 for medical reasons. She will be reassessed in the interim.

Yours truly,

[Family Physician]


Medical Report

I suspect that if I had taken just the first week off, it would have been fine. After the doctor ordered another 2 weeks, however, my boss initiated the short-term disability leave (which is the correct process.) This required me to submit a Medical Report, which was completed December 12, 2013. Doctor’s input is below in red.

Diagnosis (Please use DSM IV criteria)

Axis I Diagnosis: Adjustment Disorder

Severity of condition: Moderate

Axis II Personality Disorders (personality traits may also be noted): none noted.

Axis III Current General Medical conditions: Yes

Hypersomnolence Disorder – on Modafinil 

Axis IV Psychosocial and environmental problems (including job stressors): Yes

Job Stress

Family Stress

Axis V Global Assessment of Functioning (GAF score)

Current GAF score:

71-80 Social

51-60 Professional

Supporting Information: Describe the symptoms, objective signs and any medical or medical or psychosocial test results that support each axis of your diagnosis. 

Insomnia, restlessness, anxiety, fatigue, difficulty concentrating, easily distracted with tasks, fidgeting on examination, appears tired, soft voice

History: Copies of clinical notes included: Yes

Date symptoms first appeared: ~April 2013

Date patient ceased work because of impairment: Nov 27, 2013

Date of first visit for treatment or consultation: Nov 21, 2013

Has patient ever had the same or similar condition: Unknown

Precipitating and Complicating Factors:

Workplace issues

Social/Family issues

Coping Skills

Treatment: counselling only

Date of last visit: 12/12/2013

Frequency of visits: Weekly

Referrals to treatment providers or facility: Yes

Treatment Compliance: Yes – tried strategies

Treatment response to date: discussed during counselling 

Is your patient’s condition: improving

In order to qualify for STD benefits, eligible employees must be ‘unable to work as a result of illness or injury.’ Confirm your patient’s abilities below: (check all that apply)

Ability to comprehend and follow instructions: Yes

Ability to perform simple and repetitive tasks: Yes

Ability to maintain a work pace appropriate to a given work load: Unknown

Ability to perform complex and varied task: Yes 

Ability to relate to other people beyond giving and receiving instructions: Yes

Ability to influence people: Unknown

Ability to respond appropriately to supervision and management: Yes

Ability to make generalizations, evaluations, or decisions without immediate supervision: Yes

Ability to accept and carry out responsibility for direction, control and planning: Yes 

Please provide medical clarifications in the space below as to how the illness/injury results in an altered or inability to perform his/her duties, and the estimated duration of reduced capacity.

Patient was unable to focus due to stress/insomnia. However, she is improving and likely can return to work.  


 

First Short-Term Disability Decision: Denied

Although I thought my doctor’s note made it sufficiently clear that I had idiopathic hypersomnia and was concurrently suffering from insomnia, my first disability claim was denied.

December 23, 2013

Good Afternoon [Ulyana],

As discussed, attached is a letter regarding the status of your STD file and the appeal process should you choose to appeal this decision.  

If you are appealing, please ensure the information listed in the attached letter is provided to us at one time by the due date of January 22/14.

**There are no specific forms to be completed for your appeal.**

Thank you,

[Case Manager]

Attached letter of denial:

December 23, 2013
[Ulyana Frank]

Dear Ms. Frank:
Re: Your Short Term Disability Benefit Claim
As you know, you were referred to [benefits provider] in order for us to determine whether you are supported for Short Term Disability (STD) benefits as outlined in [Company Policy Number]. Please refer to this policy in the [Company] Policy Manual located on [Company website].
In order for you to be eligible for Short Term Disability (STD) benefits through the [Company] STD plan, you must provide medical information, as directed by your Case Manager, that supports your total disability from your position at [Company] due to a non-occupational illness or injury for which you are under the appropriate treatment.
After carefully reviewing all of the information received to date, [benefits provider] has advised [company] that your absence is not supported due to the following reason(s):
 Medical documentation does not support total disability from the job demands

As such, you will not receive STD benefits for the period outlined below:
First Day of Absence: November 28, 2013
Referral received by [benefits company]: December 6, 2013
STD claim non-supported: November 28, 2013 onwards
Expected Return-to-Work date: December 18, 2013
At this time you must contact your Manager immediately to discuss your return to work options.
You may choose to appeal this decision. To do this, you must:
1. Notify your assigned Case Manager AND your Manager within seven (7) days of the date of this letter (by December 30, 2013) AND
2. Provide new medical documentation for review to your Case Manager within thirty (30) days of the date of this letter (by January 22, 2014).

Please note that medical documentation may include, but is not limited to, the following:
 Clinical notes from your treating physician from onset of your condition (April 1, 2013) to present date
 Detailed documentation from your treatment providers outlining your medical condition, history of your condition including past treatment received, symptoms including their onset, frequency and severity, restrictions and limitations, impact your condition had on your activities of daily living, treatment plan including any changes made, and recovery prognosis

Upon receipt of the medical documentation, your appeal will be reviewed by your Case Manager and a Manager of Case Management.
For any pay related questions, please contact your Manager or the [HR Centre at telephone number]. 
[Company] is committed to accommodating your early and safe return to work. Should the need for modified duties be supported, [benefits company] will advise you and your Manager accordingly.
Thank you for your cooperation in the disability management process. If you have any questions, please do not hesitate to contact me directly.
Sincerely,
[Case Manager]

cc: [Benefits company] file

cc: [Company] HR Department

cc: [Company] Manager

Related:

Coming soon:

  • Disability claims for idiopathic hypersomnia – Part II
  • Disability claims for idiopathic hypersomnia – Part III

Mrs. Unchained 55

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