Help for Lysa Philipson: What Happens When Disability Insurance Fails at Sam Health

Lysa1It was nearing Christmas when Lysa Philipson wrote to us at The Advocate, her resources rapidly depleting, terrified by the possibility of impending homelessness and bewildered by the fact that no one seemed in a position to help her.

As the main provider of her household, now having to pay for her family’s steep private health insurance, Philipson came close to losing all she had worked so hard to secure during her dedicated employment at Good Samaritan Regional Medical Center (GSRMC). It was there Philipson served over 35 of her 55 years, mostly as an ER nurse, an occupation typical of high stress, but work she takes pride in. As stated in her initial letter enlisting our help and advocacy, Philipson claimed, “There is no better hospital in Oregon,” and that she always felt well-treated and appreciated “prior to becoming progressively ill and eventually unable to work.”

When Philipson was initially denied compensation from GSRMC’s contracted disability insurer, Lincoln Finanical Group, Samaritan representatives said their “hands were tied,” that the matter was exclusively between Philipson and Lincoln Financial, while also admitting to never coming across such a case, of someone so sick fighting so hard.

After communicating with union representatives at the Oregon Nurses Association (ONA), we’ve been assured that disability and benefits issues such as Philipson’s are being addressed amongst surveyed members of the association, prior to the next round of contract negotiations.

Since investigating her story, we can report some success for Philipson, but are still left weary and dubious of mismanagement, hoping more strides be made.

How It All Started
Philipson has battled a whole slew of health problems, most significantly since the early 2000s, including lupus, celiac disease, microscopic colitis, adrenal insufficiency, depression with anxiety, Sjogren’s syndrome, chronic abdominal pain, atrial fibrillation—and the list goes on. Philipson’s “unpredictable instantaneous episodes” of abdominal pain suddenly reached crippling degrees in the spring of 2015. Paired with having to be in the immediate vicinity of a bathroom, where she openly admits to spending up to 16 hours a day due to sudden and prolonged cramping and loose stools, Philipson’s chronic pain rendered her incapable of returning to work at GSRMSC.

“I just woke up on April 4 and all my autoimmune diseases ganged up on me” Philipson said. That day, she wound up in the ER, with abnormal labs and a CT scan.

 On a scale of 10, Philipson ranks these “gut aches from hell” averaging 8 or more, pain comparative to gunshot wounds or traumatic amputations, leaving her extremely fatigued, sometimes dry heaving.

Exhausted of all leave or vacation time, Philipson received short-term disability compensation from Lincoln Financial for a total of four weeks, the last of which she fought for. As of May 9, 2015, Philipson was denied further benefits, which she’d worked for for over 30 years. While arranging to apply for long-term disability, and facing a complete loss of income, Philipson’s only option, as per GSRMC policy, was to take out early retirement, funds crucial to her and her family’s survival during the subsequent nine-month battle for earned benefits.

“If I didn’t have that retirement money, it would have been financially devastating,” said Philipson. At the time, her family’s only other source of income was disability coverage from her husband, diagnosed with Parkinson’s and sarcoidosis, and the help of her two boys, pitching in wherever possible while attending universities.

Worse, Philipson claimed to have never received any acknowledgment for her many dedicated years at GSRMC. “Not one single person, even on the telephone, has said, ‘Thank you for all your hard work,’” Philipson confided.

Stalling Tactics and Run-Arounds
In the fall of 2015, while awaiting Lincoln’s decision over long-term disability benefits, Philipson took two trips to the ER, the first for an atrial fibrillation due to a leaky heart valve in September and the second for adrenal-related extreme dizziness in November, rendering her temporarily incapable of walking without assistance. According to Philipson, both episodes were “improved almost entirely by IV steroids… so were likely related to [her] adrenal insufficiency, which flares due to stress.”

To this day, her vertigo persists with position changes, and Philipson has since applied for and received a disability parking permit. Generally, Philipson finds extreme difficulty remaining in prolonged upright positions, in which she feels she may pass out.

Piling on to the heap of no relief, Philipson received a verdict from Lincoln on Nov. 17. Lincoln Financial had denied her long-term disability, claiming her capable of performing the “main duties” of her “regular occupation” and therefore ineligible for benefits.

Philipson suited up for a second appeal, complying with Lincoln’s vague requests for more documentation. Philipson’s husband, Howard, considers such requests potentially illegal, stating that Lincoln Financial is “required by law to stipulate exactly what they need.”

Philipson sought out two attorneys, one to assist her with Lincoln Financial and the other in applying for disability through the Social Security Administration (SSA), while also pursuing potentially helpful players, such as Larry Mullins, president and CEO of Samaritan Health Services. Loyal to Mullins through it all, Philipson refers to him as having “a tough job” and “a huge heart.” More incessantly, Philipson tried reaching Compensation and Benefits Manager Andrew Bartels.

“It took from Dec. 21 to Jan. 7 for me to even get a call back from Mr. Bartels, and that included emails from Human Resources without success, at least 10 voice messages, then two emails and more voice messages from me.” Philipson understands how busy a job like Bartels’ can be, but was desperate for answers, her only word summing up her situation: “unbelievable.”

Philipson received correspondence from Bartels after a second letter of denial from Lincoln Financial for long-term disability, dated Jan. 7. The letter claimed that the additional documents, including over 90 pages of medical records dated within the year of 2015, a doctor-written letter, and MRI of Philipson’s lower spine, were unsupportive of her qualifying for total disability, as defined by her policy.

As per this “courtesy review,” Lincoln Financial determined no evidence of impairment which would prevent Philipson from “lifting up to 50 pounds occasionally, 25 pounds frequently, with prolonged standing/walking typically a minimum six to eight hours per day from 5/09/15 and beyond due to chronic pain.”

Documentation completed by Philipson’s doctor in September of 2015, however, determines Philipson as capable of only standing or walking up to two hours within an eight-hour period, and restricted from lifting or carrying more than 10 pounds (as well as bending, squatting, crawling, climbing, and reaching above shoulder level). Also reiterated throughout the document is the unlikelihood of Philipson’s condition ever improving, that she is never expected to return to precedent functionality.

What strikes us as most dismissive of her medical examinations and physical symptoms is Lincoln’s statement that Philipson was “noted to have multiple medical complaints, but did not demonstrate any serious musculoskeletal, orthopedic, or neurological deficits.”

“They call it the invisible illness,” said Philipson, referring to autoimmune diseases. She notes how insurance companies such as Lincoln Financial prefer more black and white criteria or conclusive lab work during determination stages, as Philipson’s lab work at the time had shown negative cultures, she suspects influenced by prescribed steroids.

Crushed Hopes Continued
After the latest denial letter from Lincoln Financial and Samaritan’s initial opt for “no comment,” Philipson and The Advocate each received word from Bartels that her case had been brought to GSRMC’s Executive Committee.

What sounded like hopeful news quickly dissolved in light of the committee’s “thorough review of claims data during the three-year period that Lincoln Financial has been Samaritan’s disability insurance carrier,” during which Lincoln Financial “approved more than 86% of claims submitted and only two out of 109 claims have reached the appeals stage,” rendering Lincoln’s treatment to claimants as fair in Samaritan’s opinion.

Like Philipson, we were curious to know if her case fell under the “covered” category, as she was initially compensated for a short time, as well as how much representation there was amongst claimants with less physically evidenced disorders such as autoimmune diseases. We, alongside Philipson, urged GSRMC to acknowledge that she was not just a statistic, and that this was her life on the line. GSRMC provided no further comment.

Philipson had tried contacting both the Bureau of Labor and Industry and the Oregon Nurses Association early on, but to no avail. On Jan. 15, Philipson wrote that she spoke with ONA Labor Relations Representative Christine Hauck, who suggested sending Bartels a certified letter asking him to return Philipson’s calls.

After The Advocate reached Communications Manager Kevin Mealy, ONA took special interest in Philipson’s case and sent a letter to Samaritan, requesting she be made whole for her overdue benefits and that standards be established to prevent other employees from extended loss of earned benefits. Meanwhile, Lincoln Financial postponed their decision another 45 days—a frequented tactic—requesting Philipson see a rheumatologist, who would, according to Philipson, address the least of her problems, which she figured Lincoln was counting on.

SSA Saves the Day, Samaritan Steps Up, Kinda
With her bank account down to around $100, finally, Philipson received good news. The SSA had approved her for disability, and swiftly she’d been compensated. Even better, Bartels wrote to inform Philipson her policy had been amended, effective Feb. 9, 2016, to include SSA disability determination as a trigger for benefits, enabling her to receive Good Samaritan disability and retirement payments as of her SSA disability date (Oct. 15).

“In the last few weeks, Samaritan has been fantastic,” Philipson recently beamed, eager to tackle her appeals-related stress and focus wholly on her well-being.

Philipson believes that being approved by SSA “seals the deal” as far as Lincoln’s decision, claiming the requisites for approval through SSA are more extreme than through Lincoln Financial. At this stage, if Lincoln denies her benefits, she’ll be taking them to court.

“It doesn’t feel like her case has been fully resolved yet,” said Mealy. Like Mealy, we are glad for Philipson’s satisfaction over recent outcomes, but feel there is unfinished business.

What’s Next
Mealy and other ONA representatives want to be sure this type of situation won’t repeat itself. They’ve recently released surveys to current ONA members in lieu of possible contract changes, inclusive of questions related to long-term and short-term disability coverage, some specifically tied to Philipson’s case.

Philipson has had, through all of this, the distinct, double-fold advantage/disadvantage of having been a nurse, versed in the terminology and competence in understanding the context for her pain. For a woman who avoided routine narcotics until her 50s and now depends on them (amongst other drugs) to get by, who currently spends the majority of her days in her bathroom and bed, it is hard not to be impressed by her continued resilience.

After serving our area’s most in need for over 35 years, while employed under one of our area’s most powerful players, we find it baffling that Philipson should have to wait so long to access her hard-earned benefits. It is hoped that ONA and Samaritan Health will conduct a thorough review of Lincoln Financial as a disability provider, especially given the fact that “horror stories,” many akin to Philipson’s, litter the Web about this particular insurer.

As to Philipson herself, she chose a decades-long path of self-sacrifice, serving her community in ways few can understand, and we are touched and grateful for all her years of work. Today, she continues to battle her health and stay afloat, still speaking glowingly of her years at Samaritan and the work she so loved.

By Stevie Beisswanger