Stroke Victims: Insurance Denial And Your Rights

Strokes can have a significant financial impact on individuals and their families, with the lifetime cost of an ischemic stroke estimated at $140,048. This includes inpatient care, rehabilitation, and follow-up care. As such, it is important to understand what insurance coverage and benefits are available to stroke survivors. While health insurance companies may deny coverage for certain prescription drugs or medical services, individuals can appeal these decisions and seek support through disability benefits, social security, or employer-provided long-term disability plans. The road to recovery from a stroke can be long and challenging, and having the right protection in place can help provide financial peace of mind during this difficult time.

Qualifying for disability benefits

Strokes are a leading cause of long-term disability in the US, and they can have a significant impact on a person's ability to work and earn an income. As such, disability benefits are available to those who meet certain criteria.

Short-term disability insurance

Short-term disability insurance pays benefits directly to the insured if they are unable to work due to illness or injury. This can be used to help with deductibles, physical rehabilitation, and lost income. Most short-term disability plans offer coverage for three to six months.

Long-term disability insurance

Long-term disability insurance is for those who have experienced more severe impairments and may be unable to work again. Benefits are paid out after an initial waiting period, usually three to six months. These benefits can be used to cover medical bills, everyday expenses, and lost income for the length of time stipulated in the plan.

Qualifying criteria

To qualify for disability benefits after a stroke, you must meet certain criteria. Firstly, you must be unable to work for at least 12 months after your stroke. You must also provide proof of your stroke as described in the Neurological Impairment section of the Social Security Administration's (SSA) Blue Book. The SSA will assess whether you are unable to:

• Speak or write effectively due to expressive or sensory aphasia.
• Control the movement of at least two extremities, despite treatment, resulting in extreme difficulty with balance and movement.
• Overcome marked physical problems, along with a marked limitation in thinking, interacting with others, finishing tasks, or regulating emotions and controlling behavior.

If you have vision loss or other physical impairments as a result of a stroke, you may also qualify for disability benefits.

Medical Vocational Allowance

If you don't meet the specific Blue Book listings but are still unable to work due to medical problems caused by your stroke, you may be eligible for benefits through a Medical Vocational Allowance. Your doctor must describe your limitations on a Residual Functional Capacity evaluation form, which the SSA will examine along with your work history and skills to determine your eligibility for benefits.

Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI)

There are two types of benefits you can apply for: SSI and SSDI. SSI is for those with low incomes and few assets, while SSDI is for those who have worked and paid taxes for years. Both include health insurance (Medicare for SSDI and Medicaid for SSI).

Insurance appeals

If your insurance company denies your claim, you can appeal the decision. Providers use various names for appeals, including Request for Reconsideration, Medical Benefit Appeal, Coverage Appeal, Pharmacy Benefit Appeal, and Prescription Drug Coverage Appeal.

Reasons for Denial

Your insurance company might deny your claim for the following reasons:

• Your drug is not on their list.
• Lower-cost drugs are available.
• The company hasn't decided whether to pay for a new drug or treatment.
• Your illness doesn't match their records.
• Your prescription has a different amount, dosage, or timing than what they allow.

Appealing the Decision

To appeal a denial, follow these steps:

• Call the telephone number on your insurance card to find out how to appeal.
• Act promptly. Appeals have a time limit and take time to process.
• Ask your doctor to help with the appeal.
• Follow the steps required by your insurance company.
• Consider seeking assistance from someone with the appeal process.
• Make copies of your paperwork before submitting the appeal.
• Include your name, address, phone number, and insurance ID number in the appeal.
• Include your doctor's name, address, phone number, and any relevant treatment records and authorizations.
• Include the name of the drug or service you're appealing.
• Include other items that support your case and be as detailed as possible.
• Call your doctor and pharmacy after a few days to confirm they're working on the appeal.

Appealing a Denial of Social Security Disability Benefits

If you've suffered a stroke with long-term or permanent effects that impair your ability to work, you may be eligible for Social Security Disability benefits. If your initial claim is denied by the Social Security Administration (SSA), you can file an appeal. Here's how:

• When you receive the notice of denial, review the reason for the denial and gather the necessary information to address the issue.
• File your appeal (called a Request for Reconsideration) before the deadline specified in the denial notice, or your claim will be dismissed.
• Review the Blue Book listing for your specific condition (stroke is listed under Section 11.04) and gather supporting medical evidence to meet the listed criteria.
• Consider retaining a disability attorney, as claimants with legal representation are more likely to have their claims approved.

Social Security disability benefits

In the US, strokes are a leading cause of long-term disability, affecting around 795,000 people each year. If you have suffered a stroke, you may be eligible for Social Security Disability Insurance (SSDI). SSDI is a federal insurance program, funded by payroll taxes, that provides income if you are unable to work due to a disability.

To qualify for SSDI, you must meet certain criteria. Firstly, you must be unable to work for at least 12 months after your stroke. Secondly, you must provide proof of your stroke as described in the Neurological Impairment section of the Social Security Administration's (SSA) Blue Book. This proof typically includes diagnostic test results, hospital records, surgical notes, physical exam notes, and prescription medications, among other things.

The SSA defines a disability as a physical or mental impairment that prevents an individual from engaging in substantial gainful work and is expected to last at least 12 months or result in death. To meet the SSA's definition of a disability, you must be unable to:

• Speak or write effectively due to expressive or sensory aphasia.
• Control the movement of at least two extremities, despite treatment, resulting in extreme difficulty with balance, standing up, or using your arms.
• Overcome marked physical problems, along with a marked limitation in thinking, interacting with others, finishing tasks, or regulating emotions and controlling behavior.

If you meet the above criteria, you qualify for disability benefits under the SSA's listing. Additionally, if you have vision loss or other physical impairments as a result of a stroke, you may also qualify for disability benefits under separate listings.

If you don't qualify based on the Blue Book listings, you may still be eligible for benefits through a Medical Vocational Allowance. For this, your doctor must describe your limitations on a Residual Functional Capacity evaluation form, which the SSA will use, along with your work history and skills, to determine if you are capable of working. If they determine that you cannot work, you will be eligible for benefits.

SSDI benefits include regular monthly income, with annual cost-of-living increases, and a portion may be tax-free. Additionally, regardless of age, you become eligible for Medicare benefits 24 months after becoming eligible for SSDI.

Long-term disability insurance

• Medical bills
• Everyday expenses
• Lost income

Eligibility for long-term disability insurance

To be eligible for long-term disability insurance, you must be unable to work for at least 12 months after your stroke. You must also provide proof of your stroke as described in the Neurological Impairment section of the Social Security Administration's Blue Book.

The Disability Benefits Center, an independent nonprofit organization, lays out the following requirements for eligibility:

• You're unable to speak or write effectively due to expressive aphasia (difficulty forming words) or sensory aphasia (fluent, nonsensical speech and the inability to understand).
• You're unable to control the movement of at least two extremities (an arm and a leg, two arms, or two legs), despite at least three months of treatment, resulting in extreme difficulty balancing while standing or walking, standing up from a seated position, or using your arms.
• You're unable to overcome marked physical problems, along with a marked limitation in thinking (understanding, remembering, or applying information), interacting with others, finishing tasks (problems with concentration, persistence, or speed), or regulating emotions and controlling behavior (problems with responding to demands, adapting to changes, or being aware of normal hazards).
• You have vision loss or other physical impairments as a result of a stroke.

If you don't meet the above requirements, you may still be eligible for benefits through a Medical Vocational Allowance. For this, your doctor must describe your limitations on a Residual Functional Capacity evaluation form. The Social Security Administration will then examine this form, along with your work history and skills, to determine if you're able to work. If they decide that you're unable to work, you'll be eligible for benefits.

Supplemental Security Income

Disabled stroke survivors can become eligible for SSI as a consequence of their stroke. To be eligible, a person must be unable to work for at least 12 months after their stroke and provide proof of their stroke as described in the Neurological Impairment section of the Social Security Administration's (SSA) Blue Book.

The SSA evaluates disability claims for strokes under their Blue Book guidelines for Section 11.04 Central Nervous System Vascular Accident. To qualify, a person must have one or more of the following stroke side effects for at least three months:

• Trouble communicating well with others (e.g., unable to speak clearly, understand what others are saying, or communicate through writing)
• Difficulty standing up, sitting down, walking, maintaining balance, picking things up, reaching, handling, lifting, pushing, or pulling without help
• Trouble remembering or following basic verbal instructions, dealing with changes to their work routine, or interacting with other people as expected

The SSA won't process a claim for a minimum of three months after a stroke to ensure that the impairment is long-term.

Frequently asked questions