The accident
On December 17, 2003, I suffered a neck and shoulder injury.  This is
in California.

What happened
I was having lunch at a cafe.  Art hung on the walls.  Each art piece
was mounted in a wooden box.  The art piece was about 2' wide and 3'
in heighth.  I was sitting on a couch attached to the wall and
directly below the art.  The art fell off the wall and hit me square
on the neck.  I was pinned beneath it.

The injuries and the doctors
I am being treated by an orthopedic surgeon, a physiatrist (i.e. a
doctor who treats neck injuries), a chiropractor and physical therapy
two to three times a week.  All of them tell me that everything in the
neck and shoulder was injured -- the muscles, tendons, ligaments,
stiff joints -- all as a result of the accident.  It appears that no
disks were broken or cracked.  For weeks, I had to wear a soft collar
as I could not hold my head up.  I was in the most horrible pain. 
Medications included vicodin, norflex (a mucle relaxant) and
ibuprofen) all of which could be taken simultaneously for the pain.

All of the above listed medical personnel tell me it will take a solid
year to recover.  After one year "it's as good as it gets".

Employment and ability to work
I have been working about four hours a day.  After four hours, I am
exhausted and cannot hold my head up very well.  I am a computer
programmer so I sit at the computer and monitor typically 8, 10, even
12 hours a day.  With the injury, there is no way I could do that. 
The exercise routine for physical therapy takes about an hour and can
leave me exhausted.

Short-term disability claim
My employer used MetLife to process the short-term disability claim. 
For six months -- from December 11, 2003 through May 16, 2004 --
MetLife approved the short-term disability claim.  Thus, my employer
paid me some wages during that time as well the premiums for some
insurance benefits.  My chiropractor filled out the forms for the
short-term claim.  (He also filled out the forms for California State
disabiility which was also approved.)

Long-term disability claim
I pay the premiums for the long-term disability insurance.  My
chiropractor completed the form and added his office notes (which are
illegible).  I prepared a package consisting of the form, my typed
statement, two progress reports from the orthopedic surgeon, two
progress reports  from physical therapist, copies of the med
prescriptions, and copies of award letters from my employer and
California State.

MetLife denied the claim.  In part, they wrote: 

     Based on the informatin received, there are no objective findings
     that indicate a functional impairment that would prevent you from 
     performing your occupational duties.  Physical therapy notes 
     indicate pain decreased overall.  There are no physical exam findings
     documented.

I talked to the case manager on the phone.  She was polite but terse. 
She did say that a nurse made the decision.  She would only add that
the reasons for the denial are in the letter.

What exactly do they mean by "no objective findings" and "no physical
exam findings"?

What steps do I need to take to appeal the denial and win the appeal
on the long-term disability insurance claim?  I have six months.

Would it help my appeal to have an attorney write a cover letter, or
to even handle the whole thing?

Can you cite some web sites that tell consumer what is needed in these
kind of appeals?

Thank you.

Cynthia Diane

The issues can be very complicated, and you probably need a very specialized
lawyer.  The key issue is whether or not your policy is governed by
ERISA.  If you got it through your employer or some other group, even
if you paid the premium, it almost certainly is.  If it was
individually purchased, then it is probably not.  The difference in
litigation is huge.  Because you mention having 180 days to appeal,
that is a strong indicator that you have an ERISA-governed policy.

ERISA preempts all state insurance laws and bringing suit in state courts,
forcing you to sue in federal court only after you have been through the
insurance company's appeals process.  Furthermore, you generally are not
allowed to add any evidence into the administrative record once you file suit.
In most cases, the judge is required to apply a highly differential standard
to the insurance company's decision, making it difficult to overturn unless
you have added evidence into the record as part of the appeals process that
the insurance company ignored.

You need an attorney who is an expert in disability insurance and ERISA if you
are subject to it, and they are rare because you usually cannot collect
attorney's fees, and the law prevents the award of damages.  As a result,
some insurance companies can hide behind ERISA and engage in terrible
behavior with no risk because at worst, the courts can only make them
pay what they would have had to pay anyway.

An individual policy makes life a little easier, but most insurance companies
are extremely aggressive these days in denying claims.  There are a million
ways to screw up a claim, and many are very difficult to overcome after the
fact.  Other issues revolve around the definition of disability in the
policy and how well your physicians have documented your disability
with respect
to how it impedes your ability to work.

I highly recommend the following web site to you for general information:
http://www.disabilityinsuranceforums.com.  I suggest reading the General
Questions and Disability Insurance Claims Advice forums in their entirety to
educate yourself on what is going on.  Obviously, these are worst-case
scenarios, but they frequently occur, particularly with certain insurance
companies.  You can also post questions about your claim and receive
answers from qualified experts and other claimants.

This disability attorney, based in Virginia, has a number of interesting
documents on his web site:  "Disability Insurance Claim Denial"
BenGlassLaw.com http://www.vamedmal.com/practice_areas/disability-insurance.cfm.

While there is some overly dramatic material on the Internet about
disability claims problems, most of it is valid and useful.

I suggest you learn as much as possible about your insurance policy's
provisions and, if applicable, ERISA, so that you can interview attorneys
intelligently and make sure they know what they are talking about.  You also
want an attorney who will let you be highly involved in the litigation
process.  No attorney will ever know your claim as well as you do.

Here are some links to specific threads on the Disability Insurance
Forum that you may find particularly useful:

"Appeal and Request Information - Erisa" Disability Insurance Forums
(October 25, 2003) http://www.disabilityinsuranceforums.com/messageview.cfm?catid=4&threadid=1924&highlight_key=y&keyword1=ERISA

"Qualities for good ERISA representation" Disability Insurance Forums
(March 19, 2004) http://www.disabilityinsuranceforums.com/messageview.cfm?catid=4&threadid=2423&highlight_key=y&keyword1=ERISA

"ERISA MetLife and CFIDS" Disability Insurance Forums (March 17, 2004)
http://www.disabilityinsuranceforums.com/messageview.cfm?catid=6&threadid=2409&highlight_key=y&keyword1=ERISA

There are plenty of court cases out there decided in favor of the
claimant where insurers were chastised for ignoring self-reported
symptoms.  However, some newer disability insurance policies have
language making claims based on self-reported symptoms more difficult.
 Understanding your policy's definition of disability is critical.

Good luck pursuing your claim.  From personal experience, I advise you
to never communicate with any insurance company representative by
telephone or in person.  Your best bet is to always communicate by fax
or certified mail/return receipt requested.  Having a written record
of what you say and they say is very important.  They will
deliberately distort your statements and try to trick you into saying
things that could damage your claim.  I certainly would not
communicate with them further, even in writing, until you have
consulted an attorney.

Please request clarification if needed.

Sincerely,

Wonko

Excellent overall presentation.  Directed me to web sit forum and
specific postings within the forum.  I used the link to the form
letter and wrote my own letter.  Got educated on ERISA.  Spoke with an
attorney.  Thanks Wonko!

I think their statement about "no objective findings" means there is
no physical proof of a problem (such as an x-ray).  "Subjective" would
probably mean the person says it hurts whereas "objective" likely
means "the x-ray shows damage."  Thus, their additional statement  of
"no physical exam findings" also sounds as if they believe there is no
physical proof of an injury.

Whenever you are injured (even if you think it is minor), it is
important that you go get examined and x-rayed at the time.  If a
problem developes afterwards, then there is physical proof of the
situation at the time of injury.  An example would be if arthritis
developed in the months following the injury.

I believe the most important thing you need are x-rays.  It would be
great if you had some that were taken very shortly before the accident
(which is doubtful).  Ones taken right after the accident compared
with ones taken today would also be very helpful in proving your
claim.

Outside of x-rays, statements from your doctors are of importance.  If
they are simply saying something like "the patient experiences
pain..." then that might fall into the "subjective" category rather
than "objective."  The insurance company is wanting you to show hard
proof of damage, I believe.

I think an attorney is certainly your best chance.  As soon as the
insurance company thinks something is going to court, they'll start
weighing the cost of a payoff versus the cost of a lawsuit.  Even
better, if you get a lawyer that specializes in such claims, they can
tell you exactly what you need to do.

CD, 
to the wise and thoughtful answer from Wonko I wish to add a small suggestion.
The insurance will try dispose of your claim any way they can and so a
lot can hinge on a word--- an adjective or even a synonym of a
descriptor.
Get a valid and complete copy of the insurance contract, not just the glossy.

Perhaps if you can now sit at the keyboard for 20 minutes per day as
you strive to make good faith progress they attempt to make an
unreasonable and unwarranted extrapolation that you are "capable of
performing your duties", even though the normal workload is 8 to 10 or
even 12 hours.

So, knowing the wording of the contract can guide the treating health
care professionals to use the key words in the lexicon of the
insurance industry.

To use a driving example, there are drunk driving offences/charges
called DUI, DWI, impaired driving.  In a jurisdiction that defines an
offence of "DUI" a policeman laying a charge of "impaired driving"  
would see his charge dismissed at arraignment-- no such charge.

To the issue of of "objective" proof, such as the "x-ray shows
damage", raised by markturner, another commenter.  The overall
suggestion is helpful.
You say that you have no disk cracking or breakage.
X-RAY technology is 100 year old technology and is less capable of
providing positive proof of soft-tissue injury such as yours.  The
insurance companies
like that.

The field of Diagnostic imaging is complex and rapidly evolving. There
are CAT scans (even though based on X-RAYs, the computer makes it
orders of magnitude better), PET scans, MRIs, ultra-sound, others, and
THERMOGRAPHY.

While MRI might be of use in your situation if "prescribed", a lesser
known 20-year old technology is "thermography" --literally heat
picture.

Based on the premise that injured tissue will have either more or less
blood flow it will show up on an image as either hotter or colder than
normal.
A picture is worth a thousand words.

http://www.meditherm.com/therm_page1.htm

http://www.thermography.net/pages/thermography%20info.html

If you do a Google search for "thermography + medical" you can explore other
links.

Good luck and be resolute.  As a citizen you have the right to due process.

I just noticed that your question and its answer is 21 days old---I
hope you still see this.