Courtesy: Mike Yada
Mike Yada recalls the day in August 2020 when it became clear that his unusual symptoms – which emerged after a mild case of Covid-19 earlier in the year – were getting worse.
“I went for an easy hike, but at the end I was so out of breath I couldn’t walk back to my car,” said Yada, who before Covid would have easily traversed the flat terrain near the beach. . He had to call an Uber for the one-mile ride to his parked car.
It was the start of what Yada, 48, calls “crazy symptoms”. He experienced overwhelming fatigue that bedridden him, the inability to sit upright for more than five or 10 seconds, blurred vision making reading impossible. Walking was a challenge, and driving was out of the question.
It was suffering from the “long Covid” — a post-infectious condition involving a set of symptoms that can be disruptive at best and debilitating at worst. More than two years and many doctor’s appointments later, he is still battling these symptoms.
Yada, who worked in technology, also had to fight another battle: to maintain income replacement through disability insurance, a social benefit through his now ex-employer.
Although he recently won an appeal to reinstate these benefits after the insurer suddenly cut them, he is not sure that will last.
Many workers obtain disability coverage through an employer
A estimated at 43% of private sector workers have access to short-term disability insurance through their employer, according to the Bureau of Labor Statistics. It typically replaces 60% to 100% of an employee’s income, usually for three or six months, said Alex Henry, national practice leader at Willis Towers Watson, an insurance consultancy.
Long-term disability insurance, which is to come into effect as needed after short-term disability benefits have been exhausted, is available to 35% of workers. It typically pays 50% to 70% of a worker’s income—often until retirement age, depending on the specifics.
Refusals are common for long Covid patients
However, approval is not guaranteed. And for long Covid sufferers, denials are common, experts said.
“There are many short-term and long-term disability insurance claims that are not approved, especially for subjective symptoms,” Henry said. “Insurers tend to deal with it as they do with other subjective conditions…there is no outright denial, but they are looking for objective medical information [proof] of disability.”
While most people recover from Covid without complications, up to 30% of Americans have developed long Covid symptoms, affecting up to 23 million people, according to the US Department of Health and Human Services. These symptoms – which often appear after the original Covid infection has cleared – typically include fatigue and brain fog (an inability to think clearly), both of which can be difficult to measure.
These are symptoms that are not only disabling, but make it difficult to apply for benefits and manage a stressful situation.
President of Pandemic Patients
“What I basically see is cognitive impairment and chronic fatigue,” said Andrew Wylam, attorney and president of Pandemic Patients, a nonprofit advocacy group that helps long-time patients get support. and the services they need, which may include legal advice.
“These are symptoms that are not only disabling, but make it difficult to apply for benefits and deal with a stressful situation,” Wylam said.
Yada, based in California, had access to short-term and long-term disability insurance at the biotech company where he had worked for 10 years as a senior technical architect.
In August 2020, when his symptoms became debilitating, Yada applied for — and was approved — for short-term disability insurance benefits, first through the state of California, then through the intermediary of his company. (California is one of a handful of states with a short-term disability fund that workers can tap into, and insurers expect them to.)
Yet when he applied for long-term disability in early 2021, hoping it would kick in when his short-term benefits ran out, it was denied.
Seeing no income, he instead tried to work part-time, which his employer allowed him to do.
It didn’t go well. After 10 weeks of struggling, he filed another short-term disability claim when it was clear he was not improving.
“My employer was about to write to me for poor performance,” Yada said. “That had never happened.”
Towards the end of 2021, with five doctors agreeing that his condition was disabling, he again filed for long-term disability. It was approved.
Approvals can be overridden
Yet a few months ago – in August – Yada received a letter from the insurer saying his benefits were ending immediately because he had no “objective evidence” of disability.
This was despite his claim, including the results of a ’tilt-table test’ showing that blood flow to his brain was reduced by 33% when standing. (This is to be compared with 7% for a healthy person, according to medical research.) Simply put, the test measures what happens to a person’s autonomic nervous system – that is, blood pressure, heart rate, and other involuntary functions – when they switch from a flat position to an upright position. Yada’s results, he said, help explain why he can’t sit at a desk and can’t think straight.
“You can’t tell me that a [33%] decreased blood flow is not an issue,” Yada said.
He appealed the decision.
What can happen when a claim denial is appealed
Long-term disability insurance is subject to a federal law called ERISA (Employee Retirement Income Security Act). This means that when a claim is denied, the only immediate recourse is to appeal the decision to see if it results in a reversal.
“If they don’t completely exhaust administrative remedies with the insurance plan, they can’t sue,” Wylam said.
When a request is denied, you generally have 180 days to appeal the denial. The plan must generally consider the appeal within 45 days of receiving it.
If the appeal is unsuccessful, legal action to secure benefits becomes an option. In fact, cases of denial of long-term disability benefits for a long time Covid are on the rise across the country.
“Federal court cases are time-consuming and expensive, so these claims usually end up being settled,” said Mark Boyko, a partner at the law firm Bailey Glasser, which specializes in ERISA cases. The amounts awarded in the settlements are confidential, he said.
On the other hand, if the appeal results in a cancellation, benefits are usually retroactive to when they should have started.
That’s what happened with Yada: He recently received a letter saying that the denial appeal resulted in a reversal, with benefits retroactive to August.
Social Security disability benefits may come into play
However, Yada was also required by the insurer earlier this year to apply for Social Security Disability Insurance, commonly known as SSDI.
This requirement is typical, said Henry, of Willis Towers Watson. “If SSDI is granted, it is usually an offset from the long-term disability benefit,” he said.
For example, if your work disability benefit paid $3,000 per month and SSDI awarded you $2,000 per month, the employer-based benefit would be reduced to $1,000.
In other words, you would still get $3,000, but the government would pay part of the bill instead of the insurance company paying all of it.
Yada does not know if his SSDI request will be approved. The process is notoriously slow and rejections are frequent.
Meanwhile, because he lost his job when the insurer terminated his benefits in August, he also lost employer-sponsored health insurance. Although he chose to keep his coverage under a federal law known as COBRA, he is responsible for all premiums instead of having an employer participate. He pays around $800 a month.
He is also concerned that the insurer paying his benefits will suddenly end them again at some point.
“I’m not confident,” Yada said. “Any time they could just write me a letter and say it’s over tomorrow.”