Disability and the Perils of Pauline

by Mabel Grotzinger, National Vice President

“Life is what happens when you’re making plans.” - John Lennon

Life comes at you fast sometimes. My husband and I were planning for retirement still a few years down the road. We were planning on taking long vacations with our grandson, and spending time together at last. With each of his birthdays, as I added another candle to the cake, I would mention how many years until we could walk away from this life of railroading, at the magical age of 60. My husband was only months away from reaching 30 years of service when he was hospitalized. Many tests and two stays in the hospital stays later, we found ourselves sitting in the office of an Oncologist. The doctor told him he had worked his last day on the railroad and was to retire and enjoy the time we have left. By spreading out his remaining vacation, my husband was able to get his 30 years in, which would make a big difference it came time for me to retire. We thought the only thing we had to worry about was getting him well enough to enjoy the time he had left.

Wrong!

About two months from the time he went off sick, we received a letter from the health insurance company informing us of our right to pick up the COBRA option (a Federal requirement that allows an individual, at their own expense, to continue coverage for up to 3 years after leaving employment). The letter stated that if he was disabled we would be were eligible for coverage for the rest of the year and for the two following calendar years. This letter also stated that a statement from the doctor indicating the reason for the disability must be submitted. No form was included with the letter for this purpose, so we called the insurance company to ask of there was such a form, or if they needed a letter from the doctor. The woman he spoke with stated that they usually do not sent out the form until the employee has been off work for four months, but she would send it to us so we could have the doctor fill it out and they would keep in on file in the future. At this point, we felt we had fulfilled all the requirements set forth by the insurance company and were taken care of.

Surprise!

About a month later, my husband had to go to a specialist dentist because of his condition. The dentist informed us that we did not have insurance coverage. We were shocked. After all hadn’t we done all the right things? I called the insurance company again; however, I couldn’t get through to the representative what I was talking about. She said, according to the form submitted by the doctor, my husband was able to return to work on the 31^st of the previous month. I had a copy of the form in my hand and read it to her. The doctor had written in the space for the date to return to work: "Unknown due to current illness." She said there was nothing she could do, and that we were not insured.

Panic set in, because he was scheduled for chemotherapy the next day and I didn’t want to think about how much that would cost. I went to the only person I could think of to help me -- the Vice General Chairman. I was so upset, I don’t know how he understood me, but I guess he did because he said, “This happens all the time. I will take care of it.” His words made me feel a little better, but then they began to ring in my head." IT HAPPENS ALL THE TIME!” That meant I was not alone in this problem, which is good right? Wrong! It means there are a lot of people out there going through the same thing. I needed to know more about this situation so others wouldn’t have to go through the same trauma that we experienced.

What I learned is that after one calendar month of not performing work for a minimum of seven days in that month, the employee's name is dropped from the Carrier's list of those eligible for benefits. The health insurance coverage is automatically cancelled. The Vice General Chairman made the call to the Carrier to ensure my husband was listed as being off work because of illness. Apparently this does not happen automatically.

We received a second form for proof of disability. I took it to the doctor's office, but the office staff who routinely fill out these types of forms had difficulty interpreting it. They did the best they could and faxed it to the insurance company. Guess what? We were dropped from the insurance again, on the date the doctor signed and dated the form. The insurance company interpreted the date as the date to return to work. The doctor's staff was just as baffled as we were. Why does the insurance company make the form so ambiguous so that even the doctor's office cannot figure it out?

The most annoying part of this whole ordeal is that the insurance company does not inform an employee that he or she is dropped and no longer has insurance coverage. The employee, or family members, find this out when they try to get a prescription filled or go to the hospital.

When I called the insurance company for the third time, I finally spoke to someone who could tell me what the problem was. As it turns out, they require a date of some sort in the space where it says, "date to return to work." The doctor must put in a date, or if permanently disabled, the wording must be "Never to return to work," or "Permanently Disabled." If neither of these categories is applicable, the doctor must indicate some kind of date, such as the last day of the current calendar year. The employee, if able, can return to work prior to that date, but if the doctor is unsure when the employee will be able to return, it is best to put the end of the current calendar year.

There is a flaw in the communication between the employee and the insurance company. We were fortunate because we knew the National Contract contained provisions that an employee is entitled to health insurance for two calendar years after marking off sick, and the spouse is entitled to health insurance for one calendar year. If we had not been aware of that, we probably would have purchased the COBRA coverage out of fear, paying for coverage that was already guaranteed.

Whenever I hear the phrase, "IT HAPPENS ALL THE TIME," it sends off signals that something is wrong with the system and it needs to be fixed. If the person who handles the insurance matters in a doctor's office cannot interpret the form, then it stands to reason that the form needs to be revised. This ordeal caused our family a great deal of anxiety. When faced with serious health issues, one has enough to worry about without the added anxiety of worrying about whether or not one has health insurance coverage on a minute-to-minute basis. This is cruel and unusual treatment.

Note: Since this article was written, Mabel's husband Michael passed away from his illness. She wrote about her "perils" in the hopes that others would be aware of what can and does happen when a railroader is off work. It doesn't have to be because of a terminal illness. This occurs if the employee is off work for 30 days. The bottom line is that if the doctor doesn't fill out the ambiguous forms exactly right, the same thing could happen to any one of us.