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home / healthcare / patient stories

PATIENT STORY

Disabled & Denied

Jane Gabrilove - Santa Monica, CA
As told by Jane Gabrilove:

In June of 1994, I sustained an injury to my back and neck when I fell on a slippery floor outside of my place of employment. The ramifications of that fall still totally dominate my life -- physically and financially. For the last three years, I have been disabled and will shortly undergo a second surgery on my neck. I was depending on the long term disability insurance I had paid for, through my employer, to provide me with my only income...but because of a legal loophole in the ERISA law, the insurer brazenly refused to fulfill their contract with me.

ERISA allowed the insurance company to throw me into financial crisis, to siphon what energy the injury hadn't already taken, to "insure" that I had no viable legal recourse - and to further "insure" that the insurance company has no legal responsibility.

My insurance company has deliberately violated the terms of their agreement with me; unnecessarily delayed the processing of my claim for six months; continually withheld requests for important information; ignored repeated phone calls, faxes and mail; withheld moneys owed to me; and when finally dispersing some moneys due, did not explain the withheld money nor provide an itemization for the withheld money.

It was not until I enlisted the help of from a state legislator, a United States Representative, and the New York State Department of Insurance that I was able to get any of the money due me or any appropriate response at all from my insurance company.

My insurance company knows that because of the ERISA loophole, a dissatisfied policy holder can only do so much legally to them. Moreover, the recourse for a person like myself is extremely limited.

For example, when I went to file suit in Federal Court against my insurance company, I was told by a well-reputed law firm that I would have to pay attorney fees while the case went through the lengthy process of trial, and if I won a judgment, ERISA would shield my insurance company from having to pay punitive damages or legal fees. My insurance company would only be responsible for the amount owed for medical bills.

Worse yet, if I were to lose, I would be responsible for paying both my insurance company's legal fees and my own. So they told me that they could not help me, nor did they know of a law firm who would. They said they received many calls like mine...and they wished me luck.
I am persistent in fighting this matter because it seems clear to me that ERISA protection is influencing my insurance company's claims processing and pay-out behavior. In other words, they have no incentive to process and pay-out in an appropriate manner, because they are protected from prosecution by ERISA.

In my case, my insurance company managed to hang on to my benefit money for nearly a year! And during that time, they kept that money invested and profited from that investment, while they threw me into financial crisis. I had to drain my savings and borrow money from my family. I have not only been disabled, weak and in excruciating pain, but have had to live in constant worry because my insurance company was blithely "stonewalling" me. I have spent hundreds of hours trying to contact them and petitioning for help.

Contrary to what it would seem to offer, ERISA affords no realistic legal redress for my insurance company's behavior. In fact, ERISA enables insurance companies to defraud policy holders with the assurance that they cannot be exposed or held responsible for their behavior in any meaningful way.

I worry that many injured and disabled people cannot put forth the effort or have the knowledge I have to fight this battle. Many people with valid insurance suffer physically and financially from the negligence that ERISA encourages. Had I not persistently battled with my insurance company every step of the way by writing letters, documenting every transaction, faxing to numerous places, copying every hard copy paper, enlisting Congressional support, sending countless certified letters to all people and companies involved, I would not have been financially or medically aided.

I have now spent four years contending with this laborious and time consuming process. Had I gotten my disability insurance through my personal insurance agent I would of at least had legal recourse.

I believe the ERISA loophole must be changed in order for insurance companies to behave properly. Under the current ERISA protection, the insurance companies have no incentive to do so.




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