Photo: Rosalie The Rabbit from New Mexico.
March 2, 2015
VIA CERTIFIED MAIL,
RETURN RECEIPT REQUESTED
Social Security Administration
Office of Public Inquiries
1100 West High Rise
6401 Security Blvd.
Baltimore, MD 21235
VIA CERTIFIED MAIL,
RETURN RECEIPT REQUESTED
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244
Copy VIA FAX 800-447-2498
Mr. Donald Beaudette
Ms. Katherine Durrell
The Benefits Center
Post Office Box 100158
Columbia, SC 29202-3158
Unum Reference: Claimant: Johnna Stahl
Claim No. ***
Policy No. ***
Unum Life Insurance Company of America
RE: Johnna Stahl
Social Security No. ***
Dear SSA and Medicare:
I am writing for the following reasons:
1. To find out where my disability file is located, since I recently moved from Texas to New Mexico;
2. To request a change to Form SSA-831 (from 2004);
3. To submit questions to Medicare regarding coverage for certain health care services; and
4. To submit an update for my Social Security (“SS”) file.
Form 831, Primary and Secondary Diagnoses
I was recently given access to Form 831 (dated 4/16/2004 and 7/21/2004) from the copy of my SS file kept by Unum, my long term disability insurance company. On these forms, my primary disability is listed as Major Depressive Disorder, a condition I have never been diagnosed with or suffered from.
As my medical history shows, I have suffered from Intractable Pain for almost thirty years. It began as TMJ and then developed into Degenerative Disk Disease and other degenerative conditions. During my pain career, there have been a few doctors who wrote down a diagnosis of Fibromyalgia in my file — but my own research indicates that I do not suffer from that condition, even though it has been listed as a secondary reason for my disability on one of the Form 831s.
I understand there is no listing for TMJ on the SSA Listing of Impairments, although I believe it should be listed under: 1.01 Category of Impairments, Musculoskeletal.
It is my contention that the jaw joints are one of the vitally important, weight-bearing joints in the body, and therefore should be included in the Listing of Impairments. Severe dysfunction in these joints results in difficulty with the daily functions of living, like eating and talking — what could arguably be defined as two of the most important functions of the human body. But it is the constant pain from these degenerative conditions that caused me to become disabled, not the conditions themselves or any comorbid mental conditions that have arisen from my chronic pain. Also, TMJ with chronic pain includes the involvement of major peripheral joints, including the neck, shoulders, arms and hands.
I’d like to make a formal request for a change to the Listing of Impairments, to include the condition of Tempormandibular Joint Dysfunction (“TMJ”) within its definition for Musculoskeletal Impairments.
But I believe my degenerative conditions should be a secondary reason for my disability, with Intractable Pain being the primary reason I am unable to work. Unfortunately, I couldn’t find any kind of definition for chronic pain syndromes in the Listing of Impairments, so I am at a loss as to the specific request I need to make to change/update Form 831.
However, I am almost 100% sure that I do not suffer from Major Depressive Disorder, especially after further researching this illness. While I can’t know what every doctor I have ever seen has written in my medical files, I can honestly say I have never heard that diagnosis from a doctor before. In the past, anti-depressants were prescribed to me for the treatment and management of chronic pain, not for MDD.
Unum has recently terminated my benefits, and because of that, sent me a copy of my file. I found the two Form 831s in this file, but I can’t be sure this information is complete. If my SS file includes additional forms or attachments, please send me a copy (for example, Form SSA-4268: Explanation of Determination; Form SSA-4734-U8: Residual Functional Capacity Assessment; or Form SSA-4734-F4-SUP: Mental Residual Functional Capacity Assessment).
By copy of this letter, I am again requesting that the deadline for my Unum appeal be extended, as I await a response from SS and Medicare to all of these matters. I would also ask that SS request a copy of my file from Unum, as that might be the only way I will have access to the complete file.
As part of the reason for its termination of my benefits, Unum contends that my policy only covers two years for mental illness disabilities — and it’s using SS’s determination of Major Depressive Disorder to back up its claim. Additionally, Unum also considers Fibromyalgia to be a mental illness, and uses this diagnosis to terminate benefits after two years of coverage.
So you see, unless these forms are corrected, I have no recourse with Unum, especially considering this is an ERISA matter. And as everyone knows, unless I can afford an attorney to file suit after Unum denies my appeal, I’ll have no other recourse to reinstate my benefits. After 7 years of receiving LTD benefits, perhaps you can understand the magnitude of this threat against me.
In support of removing Major Depressive Disorder as my primary disability, I further submit two medical reviews of my case from doctors at Unum:
Response: Kertay, Les P 02/27/2004 14:27:00:
Ms. Herbert’s analysis as presented in the 2/24/2004 review, as it pertains to psychiatric issues in the claim, adequately and succinctly captures the essence of our discussion and my review of the relevant data. I concur that the records available in the file, over a number of years and multiple providers, are suggestive of psychological factors that likely contribute to the claimant’s perception of pain and her reactions to it. However, there is no current documentation of treatment, evaluation, or clinical formulation that attributes impairment to psychiatric condition, either alone or as it might contribute to a general medical condition. I will be glad to discuss further or to respond to any questions.
Les Kertay, Ph.D., ABPP
VP, Medical Director
Licensed Health Services Provider (TN, GA)
Diplomate in Clinical Psychology, American Board of Professional Psychology
QPS Behavioral Health Unit: Internal Correspondence
From: Thomas M. Pendergrass RN, PhD, Chattanooga Benefits Center (12/07/2004)
CONCLUSIONS: Some degree of anxiety and depression was present and briefly described in the medical records. The treating professionals did not present formal psychiatric diagnoses and treatment [sic] of these symptoms was of relative low intensity. Treatment tended to focus on the general medical conditions and any associated psychiatric symptoms were described as reactive. In my opinion, within a reasonable degree of psychological certainty, the available records do not suggest or describe psychiatric symptoms which would result in functional limitations as a primary disorder. There is insufficient assessment or treatment data to suggest that the psychiatric symptoms would provide a major contribution to the existing general medical conditions.
It was a neurologist and a psychologist who diagnosed me with Major Depressive Disorder on the two different Form 831s. At this time, I am requesting that SS have a pain specialist review my file for the purposes of updating this form and my SS file.
I am also requesting that Medicare cover the cost of a Functional Capacity Examination, as Unum is demanding that I pay for one to reinstate my benefits. Unfortunately for me (but fortunately for Unum), I cannot afford to pay for this type of service. Unum is also demanding I pay for a doctor to fill out and sign updated disability forms for its file — since I can’t pay for this either, I am requesting that Medicare cover this cost as part of the FCE. Both of these services will provide SS with the information needed to correctly update my file.
Let me be clear: I don’t believe an FCE — a one-time, painful, 2-hour, dog-and-pony-show — can assess the extent of my disabilities. I also believe the results of this examination, no matter what they are, will be used against me by Unum, if not SS. But I don’t see any other way forward, as these are the only “exams” used to “prove” disability.
I am being forced to pay for health care services I neither want or need, and since the only insurance I have is Medicare, Unum is forcing these costs on both of us.
Updated Medical History
As an update for my SS file, I am enclosing a copy of a medical history I prepared after moving to New Mexico to join this state’s Medical Cannabis Program. As my medical history shows, I have tried almost every other treatment for pain.
Not only have I run out of treatment options, as a pain patient, the medical industry considers me a drug addict and potential criminal. As a pain patient, I am subject to medication contracts, expensive urine and lab tests, pill counts, and the threat of having my name turned into the DEA if a doctor or pharmacist thinks I’m addicted to prescription medications.
After 25 years of seeking out treatment within the medical industry, I really don’t know what other services I’m supposed to be looking and paying for so that my disabilities can continue to be proven, over and over again. I am permanently disabled and doctors can’t help me. I’ve accepted this — after all, I don’t have any choice. Perhaps it’s time that SS, Medicare, and Unum accept it also.
The problem is that Unum contends that I am not disabled unless I’m under the “Regular Care” of a doctor. But Unum refuses to define what Regular Care consists of, especially for an intractable pain patient. Does Regular Care include filling out forms for Unum’s files? Will Medicare cover whatever Regular Care is demanded by Unum?
It’s taken me a very long time to create my own home treatment program, which does not include the expensive services of a doctor. The medical industry has already taken all of my money; seriously, there’s nothing left.
I know that SS and Medicare are not in any way bound by my LTD contract with Unum. All I have to support me in this fight is ERISA, and that’s just too sad to be funny. But I think it’s SS’s duty to correct my file, and Medicare is the only insurance coverage that I have.
Unfortunately for me (but fortunately for Medicare), medical cannabis isn’t covered by insurance, which means I’m paying for all of this treatment myself (along with paying for mandatory prescription drug coverage I’m not using). If I derived benefits from therapies like acupuncture or massage, I’d also have to pay for those therapies out-of-pocket. I really wish treatments like that helped me because they’re a lot less expensive than medical cannabis.
The costs of the move to New Mexico, and one year in the Medical Cannabis Program, have totally depleted my financial resources — not to mention Unum’s termination of my LTD benefits. In other words, I wouldn’t be writing this letter if I had any other options.
Although I paid for the initial cost of certification through two doctors, I didn’t submit these bills for reimbursement to Medicare. But if I’m able to afford the cost of a renewal sometime in the future, I’d like to know if Medicare will cover the doctor’s certification.
Yes, I know cannabis is still federally illegal, but I can’t do anything about that. And I’m wondering what the federal government, including SS and Medicare, expect chronic pain patients to do at this point. Restricting and refusing access to opioid therapy, criminalizing doctors and their patients, closing down thousands of pain clinics — all this leaves few options for treatment, especially any that I haven’t already tried.
I was forced to stop opioid therapy. I’m off all the pills, isn’t that great? Isn’t that what everybody wants pain patients to do?
And then what? What are the alternative, affordable treatments that work as well as opioids? At this point, what are my options for managing constant pain? How narrow will my options become in the future? Can you imagine what the future looks like for someone who has been suffering from constant pain for a quarter of a century?
One of my potential options is the right-to-die law, which New Mexico has passed. Considering all of the above, at this time, I would like to know if Medicare covers the medical services required under this state law.
(Also posted at painkills2.wordpress.com.)