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Prudential Financial And Lincoln Also Bad Apples

Although Unum Group is publicly known as the worst “bad apple” company in America, Prudential Financial and Lincoln are the runners-up that we don’t hear too much about. I’m already hearing case scenarios that indicate to me these two additional companies have jumped on the “egregious claims practices train” and are also denying legitimate claims.

In my opinion, Prudential has always been an egregious disability company, having quite a few claims review practices that are definitely in violation of “fiduciary duty.” Its claims practices are second only to Unum; and, the company definitely has a public reputation of  violations of “good faith and fair dealing” standards.

One of its most outrageous claims practices is that it utilizes RNs to conduct medical claim reviews in lieu of qualified physicians. These nurses have no specified specialties in certain impairments, and clearly are sub-standard reviewers of medical information. When you consider that many disability claims involve high-value financial reserves hitting 1M or more, having a RN review claims is like having a High School graduate review data on which someone bet millions of dollars.

Prudential, is by far, the top company that consistently misrepresents mental and nervous information from patient notes. In this respect, the company is rotten to the core. (Pun intended.) It is also the one company that will deny claims if therapists refuse to provide actual psychotherapy notes (even though they don’t have to). I have probably read hundreds of Prudential’s medical reviews (by RNs) where the slightest mention of “patient is doing well”, or, patient is somewhat better, was used to deny claims.

Prudential also has several tricks up its sleeve such as denying STD in the 24th week of STD and then alleging the claimant didn’t meet the EP for LTD. What a manipulation that is! Again, in my opinion, Prudential lacks credibility for its medical reviews, interpretations of patient notes, and “tricks” of manipulating timelines.

Lincoln, right now, is operating in its own twilight zone applying Plan provisions it knows nothing about. Personally, I believe the company is third in line for unfair claims practices, mostly because it keeps alleging it didn’t get information faxed, emailed or sent by insureds. If its internal paper machine is that bad, then it needs an internal do-over of its communication center. In the meantime, claims are being denied for no legitimate reason.

Just wanted to remind readers that Unum Group isn’t the only “bad apple” in the barrel. There are many others out there doing basically the same things to NOT pay claims.

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Physician’s Who Won’t Take The Time to Do A Good Job

Does your physician just scribble short answers on your medical update forms? Do you let that form stand and just send it in anyway? Unfortunately, that’s not going to work as well for you as it could. When insurance companies are back to “stacking the deck”, as they now are, , a well-completed medical form is just what’s needed.

I’ve been a Consultant for a long time now, and I can tell you that in the “aggressive” insurance environment we now live in, a short, one work answer medical form isn’t going to cut it.

What does surprise me is that insureds seem OK with it, and actually feel glad that they were able to get a filled out form at all. Let me go over what these update forms need to document and then you can compare your doctor’s form with these requirements.

  • The form must clearly state what your Primary and Secondary Diagnoses are complete with ICD-10 Codes. Second, the form should always contain the following information.
  • Restrictions and Limitations and why you are unable to work. Many of the forms I’m reviewing today do NOT contain R&Ls. For explanation, “Restrictions” are work activities you may NEVER DO and “Limitations” are work duties you may do, but only to a limited extent. “This patient is restricted from attempting any work in which she is likely to be unsuccessful.”
  • If you are “totally and permanently disabled”, then your doctor needs to say so, “Based on this patient’s long-term medical history, treatment ad consultation, he/she is determined to be totally and permanently disabled.”
  • Prognosis: Prognosis should be indicated somewhere on the form.
  • Treatment Plan, should be specifically defined, and more than just a few words. “This patient is recommended to cease all work activity while engaged in medication management, physical therapy, consultation and further treatment.” This is a short example, but whatever pertains to you, it should be clearly defined.
  • A statement about daily activity and the inability to perform Activities of Daily Living should be included. “This patient is recommended to remain physically active as able with moderate levels of exercise, such as walking.”
  • A statement that the current clinical consultations and treatment is “appropriate and regular care.”
  • A statement that patient notes will be provided with appropriate authorization, but that the office will not communicate health issues by phone.

As an aside, please take a look at the last form completed by your physician and see if it includes these criteria. If it doesn’t, then Release Point, Clamify, or your Claims Handler will keep “bugging” your physician for more information, and your doctor is no longer a happy camper.

I’ve been trying for years to convince treating physicians to “invoice” insurers when they contact physicians directly. Listen carefully here…..If a request for medical records is sent to the insured, then it is the insured’s responsibility to provide the information. But, when the doctor is contacted directly by the insurer for patient notes, he/she can bill the insurer for reasonable costs and only release the records when payment is received. Unfortunately, insureds PANIC and ask that the information be sent anyway, even when it is a poorly completed update form. Or worse, the doctor faxes the information directly to the insurer leaving the patient guessing as to what was reported.

Most readers are probably thinking, “My doctor does whatever he’s going to do, how can I change that? I’m just glad he fills it out at all!” While this might be somewhat true, a badly completed medical form isn’t helping you maintain benefits.

I am surprised sometimes how little patients actually discuss anything with their physicians, including the requirements of disability reporting. About half of treating physicians today use types of “medical software” that DOES NOT INCLUDE INPUT FIELDS FOR medical R&Ls. Even the patient notes are devoid of this information.

Disability reporting is unique and different from any other reporting. It is the patient’s responsibility to discuss reporting criteria with their physicians. Some people actually tell me, though, they are afraid to talk about it with their physicians. Today, physicians are operating under the “15 minutes office call” rule, and won’t take the time for do a form right even if you asked them to. Unfortunately, physicians just give the form to their nurses and ask them to fill it out. That’s not good at all!

Please be aware of the criteria I’ve mentioned above the next time you read a completed form by your doctor, and mentally do a checklist. What is written on the form, is up to you, and whether or not your doctor has a good understanding of what needs to be on the form for disability purposes. What I’m saying is that you should no longer send in mediocre forms and expect to keep receiving your benefits. It’s not going to happen in the “unfair claims evaluation mode” we’re now in.

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Trespassing Surveillance – Don’t Be Afraid!

Although location surveillance wasn’t used very much during the COV_D years, it is resurfacing with a vengeance. As you can imagine, surveillance investigators are crossing the line and are actually knocking on doors demanding to be let in for an interview.

This kind of over-the-top activity scares the heck out of people. Generally, when a surveillance team doesn’t SEE you, they knock on the door, of all things, to find out where you are. They peep into windows for movement inside, and some investigators scare insureds by telling them, “I’ll be back.”

Investigators have no right to be on your property and certainly don’t have the right to demand you let them in. Living in a guarded community might be more difficult for them, but the situation can still be managed.

DCS,Inc. always recommends placing a “No Trespassing” sign on your property, making sure your delivery people know this sign does not pertain to them. This way, if a boisterous individual keeps banging on your door demanding entry, you can call the police and file “trespassing” charges. Under no circumstances should insureds allow these investigators inside their homes.

Now that the “gloves are off” again, so to speak, it is important to protect yourselves from activities that cause you to live in fear. Do not hesitate to call the police, but first, you have to have your property posted.

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Release Point Is Making Your Doctor Angry!

Release Point is one of several upcoming “third-party paper chasers” employed by disability insurers to literally chase down your medical records for the insurance company. Companies such as Claimify, MONY, GENEX and others are paid to obtain medical records for insurance companies. Although in the past they were basically mildly annoying, the last few months have shown them to be harassing, rude, and causing your doctors to be extremely angry.

Not only are they calling treating physicians several times a day, they also harass insureds for signed Authorizations, and will contact YOU several times a day if they need to.

My advice to insureds is NOT to deal with any paper chaser directly. They are just hired guns and have no decision-making authority over your claims whatsoever. If you have sent records and forms yourself, send a fax to the claims handler, or “team”, asking them to cease and desist from annoying your doctors.

Unfortunately, physicians are getting so angry that they are asking patients to go somewhere else. and no one really wants that.

My recommendation is to never deal with the paper chasers directly, but go  to the claims handler. YOU can always obtain the information yourself and send it in. Request that your claims handler call off their hired guns if your physician is really irritated with them. Release Point is over the top harassing and awful at this point.

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Really Awful Claims Practices – Again! The METS Scam

As most of you know, I continue to have access to disability attorneys across the country, particularly those who stood with me back in 2004 to hold insurers accountable for their bad faith.

According to those I’ve spoken to recently, it appears that Unum (and other insurers) are worse than they’ve ever been. Lincoln and Guardian are close runners-up when it comes to aggressive claims management.

One of the scams I wrote about 10 years ago is back with a vengence. This particular scam involves using METS (Metabolic Equivalents) to determine functional capacity for work. METS are defined as the amount of energy expended as compared to the energy needed for sitting in a chair. Therefore, if someone had 5 METS, it means that “the activity” in questions requires 5 times the energy to do then sitting quietly in a chair.Of course insurance companies have given various definitions of work capacity based on the number of METS achieved.

Why do you think you are always asked on the update forms what your activities are? Or, whether you do your own laundry, or gardening? These questions trap the insured in to giving themselves “work capacity.” For example, doing laundry and carrying it upstairs is the equivalent of 7 METS, which insurers define as “Light” functional capacity for work. There are no published standards for using METS to determine functional capacity, other than what the insurance company “thinks they are”.

The problem with using METS to define work capacity is that METS measure performance “at a specific moment in time.” The METS ratio DOES NOT prove, or define “endurance”, or the ability to “consistently, or sustainably” perform physical activity over time, say for an 8-hour day. Nevertheless, insurance companies jump in with both feet and deny claims because an insured tested out at 7.5 METS on a cardiac stress test. This is why insurers are always chasing stress and PFT test results.

You can easily see the problem when, if an insured had a “good” day and ran on a treadmill for 7.5 METS on a stress test, but in reality only has “sedentary work capacity”, which is usually 5 METS or under. In addition, certain medical impairments cause fatigue over the course of an 8-hour work day. The ratio of METS achievable will decline over the course of a day just due to fatigue alone. Therefore, using METS to allege insureds are capable of “consistent and sustainable” full-time work capacity is a fallacy, and they think we’re stupid enough to believe it.

Insurance companies have been doing this for 20 years, but an unknowing public and their attorneys have allowed it without challenge. Perhaps it is time again to challenge everything an insurance company does and says. What is scary though, is that there is not going to be chance of public out cry to blow the whistle and make things better.

Companies like Guardian take another tack to their bad faith. It appears they NEVER stop “investigating” claims – ever. I know of one claim that has been under “investigation” (if you believe the letters) for about a year and a half. Once medical records are obtained, the company seems to start all over again, and the harassment continues for the duration of the claim. With Guardian there never seems to be enough records for “proof of claim. The Standard’s arguments rest with “we never received the records.” Unum is sending out letters saying the only thing they received is the APS form.

Now is not going to be a good time to think that you have all the answers to keeping your disability claim. These insurance scams can be undone, but you need to know how they work and what to do about it. I’m not trying to scare anyone, but those of us who worked in the insurance industry 20 years ago know how devastating it can be to lose a claim due to these internal scams.

If you would like to speak to me, please feel free to send an email and leave your number. It’s time again for insureds to take their heads out of the sand and realize what’s what – again.

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Disability Claimant’s Bill of Rights

As a direct party, or participant, to a disability contract involving insurance coverage or income replacement, you are entitled to generally recognized rights of expectation that the provisions agreed to in the Plan or policy contract are adjudicated in a fair, unbiased and equitable manner by disability insurers.

You have the right to full disclosure

As the insured party to a disability contract you have the right to receive and examine all collected data, both paper and electronic, collected by the disability insurer in the process of reviewing your claim for benefits, but only when your claim is denied. This includes all administrative and chronological records, conversations, meetings, data base checks, electronic website information, field surveillance, website portal information, and any other data affecting your privacy as an individual. The insurance company, to deny your claim for benefits, must have relied upon disclosure information. Under ERISA regulations you have the right to receive a copy of your Plan and Administrative Record within 30 days of requesting it. If it has not been provided to you within the designated time frame, the insurance company may be fined $110 per day although there is no one overseeing the fine or enforcing it.

You have the right to privacy and respect.

You have the right to expect medical records and any other private information that reflects upon your credibility, integrity or reputation, to be kept private and communicated with respect. You have the right to know what type of information is requested over and above that which is needed in making a fair decision on your claim. You have the right to know when your claim is being reviewed in a public forum and by whom. (Such as roundtables.) You also have the right to know the name and title of the person who will actually be making the decisions on your claim. Quite often, it is not the claims specialists who do this.

You have the right to a timely claim decision

You have the right to expect your disability insurer will make every effort to render a claims decision within 45 days (ERISA claims) or that period of time indicated in the policy provisions. You have the right to be notified in writing every 30-45 days as to the reason why your claim decision is delayed. ERISA regulations require the insurance company keep you informed by sending “tolling letters” if the claim decision is not make within the 45-day period.

You have the right to a fair and objective claim review

You have the fiduciary right to expect your disability insurer will make every effort to consider ALL recommendations and opinions given to the insurer by your primary care physicians, consultants, counselors, and any other specialist who is qualified to render an opinion concerning your ability to work. (ERISA claims or industry standards if an Individual Disability policy) You have the right to expect the disability insurer will consider the experience and qualifications of your doctor as equal to those of its own in-house physicians, and to make fair and honest attempts to reconcile professional differences of opinion.

You have the right to fair representation of facts

As the insured you have the right to a clear understanding as to the party or parties responsible for making the liability decision for your claim. You have the right to know who is authoring communications to you from your insurer, and the names of all employees, consultants, directors, and others who are offering medical or administrative opinions concerning the facts of your claim. You also have the expectation of unbiased medical review and internal medical opinions that inherently will not cause you or others future harm.

You have the right to withhold authorization of release of information that is overly broad; and to receive explanations as to why private information unrelated to your claim is requested.

Any individual has the right to retain privacy rights to information without fear of loss of benefits. It is your right not to sign Authorizations of Release which are overly broad, or, which allows the disability insurer to obtain information outside of what is required for a fair and objective review of your claim within the provisions of your policy. Many of the newer ERISA disability policies contain provisions which require you to sign an Authorization and cooperate with the insurance company or risk loss of benefits.

You have the right to ask questions

As an individual outside of the specialty of the insurance industry, or understanding of that industry, you have the right to knowledge, explanation, definition, instruction and full understanding of the provisions of your policy without fear of loss of benefits.  You have the right to ask questions concerning your claim as often as is necessary for your understanding of the facts without fear of retaliation, suspicion, or unfair investigation tactics. You have the right to obtain and retain any additional assistance if needed.

You have the right to ethical conduct

As an insured you have the right to expect your disability insurer, and its representative employees act in “good faith and fair dealing.” You have the right as an employee or policyholder to expect your insurance company creates and maintains a clearly defined disability claims review process which lends toward the fair, objective and timely, review of all claims submitted as part of its product business.  You have the right to expect your insurance company have in place a process that routinely and consistently corrects flaws within the review process; recruits, trains and retains individuals qualified to review disability claims; and provides a forum for independent appeal processes.

You have the right of non-discrimination

All insureds have the right to expect their insurance company not discriminate on the basis of indemnity amount, self-reported or physical impairment, education, training or experience, occupation, age, sexual orientation, mental and nervous disorder, policyholder, geographical region, claim location, event, physician, claim duration, months of paid benefits, or any other target objective identified by management. You have the right of expectation that your claim will not be targeted by management for denial as a “block of business” due to any of the above.

You have the right of appeal. (ERISA)

As an insured covered under the Employment Retirement Security Act of 1974 (ERISA) you have the right to a timely independent appeal review of your claim. For non-ERISA individual disability claims, you have the right to report discrepancies to your state authorities and to retain legal counsel, and request “reconsideration” of any denial decision.

Linda Nee, a Disability Claims Consultant, wrote this “Bill of Rights”. Although there is no law or regulation upholding these rights as an official document, the rights described therein are reasonable and should be expected from any disability insurer with a duty to uphold generally accepted industry standards to review claims objectively, and without bias or financial prejudice.

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New White Paper – Managing Personal Phone Interviews

 

I’ve just updated a White Paper I wrote entitled “Managing Personal Phone Interviews”.

I am happy to email it to anyone who makes a Donation in any amount from my website.I will also require a email stating that you will not publish my work anywhere on the Internet, or share it with anyone without my permission.

Current DCS, Inc. clients may request the 7 page article for free.

Those insureds who are still speaking to reps on the phone might find it helpful.

http://www.disabilityclaimssolutions.com

 

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Don’t Let Questionnaires And Narratives Rattle You

 

Every insurance company has their own versions of multiple questionnaires and narratives. These requests are NOT an opportunity for insureds to reduce their handwriting and printing to microscopic letters. In fact, while many of the questions on the questionnaire are wolves in sheep’s clothing, the answers are intended to be short and to the point.

In reality, insurers are permitted to ask you questions about your occupation, your impairment, and your finances. Beyond that, the questions are usually undercover questions written to find out what your functional capacity is so that insurers can use the information against you if they can.

Insurers have ways to determine work capacity from activities you describe. For example, gardening is the equivalent to 5-10 Mets which is at least sedentary capacity. Doing laundry in the cellar, carrying clothes upstairs and down is equivalent to 10+ Mets, which could be interpreted as “light functional capacity.” Let’s put it this way, the questions you are asked have been proven to be profitable, and that’s why insurers keep asking them again and again.

One of the most profitable questionnaire answered questions about activity voluntarily is, “I babysit my grandchildren on a regular basis.” This one question has probably produced more profit than any other. Insurers always claim anyone who babysits during the day can work.

Prudential denied a claim once because it was mentioned in a therapy note that the insured’s boyfriend lived with her and did not work. It was interesting how Prudential weaved that one into its denial. Questionnaires contain “trick” questions as well such as, “Describe your usual daily activities”, or some version of this question. Most people will begin to write about when they get up in the morning and describe everything they do until they go to bed. WRONG! Don’t do that!

This question pushes you to answer with much detail because it is an aid to “surveillance activity”. Details   are NOT your friend when you have a disability claim. In fact, insureds should always answer truthfully, but only giving generic, or sterile answers. “Yes and No” are still very good responses.

Most insureds who receive questionnaires will reduce their handwriting just so they can write more information in the small spaces provided, or will attached pages, and on and on. This is a mistake.

Many insureds tell me, “I haven’t seen this form before.” It’s OK, most insurers have several versions of questionnaires – one they send to you, and one they send to your doctor. The points I’m trying to make here is that insureds should always answer truthfully only what they are asked, not providing detail.

It is so risky to volunteer information you aren’t asked when you have a disability claim. Keep your answers simple and to the point. Do not volunteer information. Remember, an insurance company can’t hold against you what you do not write. And, don’t let getting a questionnaire “rattle you.” In the whole scheme of things, a questionnaire is not that critical to a disability claim.

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Are You OVER SPEAKING Your Claim? Careful

There are still many insureds who choose to speak to insurance companies on the phone even when doing so is not an insurance claim best practice.

Today, for some reason, insureds and claimants seem to “believe” exactly what they are told by insurers even when they are aware of the conflict of interest, namely, that insurers are both reviewers and payers of claims. Even in an environment where a large majority of claims handlers can’t speak good English, it is possible to be duped by a claims handler seeking information to use to deny your claim.

Insurance companies are paranoid about two things – 1) insureds are working and not claiming the income, and, 2) claimants are receiving SSDI and haven’t told anyone. Because an insurance company is “an arm’s length away” from information they need, it is constantly seeking data from you. If they don’t get the data they need, they become paranoid.

As a result, a phone call is typically made to obtain what you think is a update, but the conversation also has an agenda of its own. Official phone calls from insurance companies are planned, programmed, and potentially harmful. Most insurance companies have distributed “templates” to be used as guidelines for questions that have nothing to do with disability claims. Let’s be honest – the obvious intent of a phone conversation is to prompt insureds on the phone to provide information that can be used against them.

What insureds often do not realize is that there is no disability on this planet that requires phone calls as “proof of claim”. Plans and policies DO NOT REQUIRE ANYONE TO SPEAK WITH INSURERS ON THE PHONE. Insureds ARE required to provide continued proof of claim when requested to do so, but may do that in any way they see fit. Any insurance company that tells you you HAVE to speak to them on the phone should be asked to provide you with the page from your Plan or policy that requires you to do so. Hint: it doesn’t exist.

Whether insureds are aware, or not aware, of the insurance agenda, some still think nothing of picking up the phone, calling the claims handler, and sharing far more information than they should. I call this OVER SPEAKING your claim. If you know the insurance companys’ interests conflict with your interests, why would you go ahead and share information you know could be used against you? It defies logic to me, and it risks claims.

Here are a few myths commonly believed by insureds that often put their claims in jeopardy.

    • Insureds think that if they do not share every little detail about their claims, the insurance company won’t pay them. In reality, it’s exactly the opposite; insureds create “red flags” by volunteering information over and above that required to have a disability claim.
    • Insureds may believe that  advertised “claim best practices” are all a bunch of bunk, and after all, insurers really aren’t all that bad, and aren’t trying to deny them.
    • Insureds OVER SPEAK their claims because they think it makes claims seem more credible. Wrong. Nothing you actually say is documented like you say it, so how credible can that be?
    • Insureds think if they don’t do every thing their insurers ask of them, it will be “mad at them” and deny their claims.
    • If I don’t speak with my insurer on the phone, it makes me look bad.”
    • Insureds tend to trust themselves to speak with insurance companies even when they are taking opiate, pain or depression medications that could distort what they say.

These are just a few “bad habits” that insureds tend to believe without question. Let me remind you that insurers are seeking information about you, and they do not distinguish between what is needed to pay claims versus what is needed to challenge your credibility.

What I would like to leave you with in this article is this: AN INSURANCE COMPANY CANNOT HOLD AGAINST YOU WHAT YOU DO NOT SAY (OR WRITE). Do not be so anxious to talk, and talk, and talk on the phone with any insurance company. Only send written communications and if possible, stay off of the website portals.

On those occasions when insureds ignore “best practice recommendations”, claims decisions don’t usually turn out well for them. Claims handlers are definitely NOT sharing the whole story with you, so it’s a good claims practice NOT to speak with any claims handler on the phone. Protect yourself and listen to the people who know.

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The Issue Of SSDI Overpayments

As most ERISA claimants know,  LTD group policies contain a provision allowing for the reduction of monthly benefits by any amounts received from SSDI. This means your disability insurer has been allowed by law to use the social security system to “finance” part of their liability, which they are committed to pay you, if your claim is approved.

I strongly recommend to all my ERISA clients that they obtain copies of their original Plans while still employed and read through the Plan provisions relating to “Other Income” in order to gain a clear understanding of each parties’ obligations when receiving SSDI. You should pay particular attention to whether your Plan allows for an offset of your SSDI award, awards for your children, or does not allow any offset. (Non-integrated policies) There should be no surprises when it comes to the issue of SSDI at the time of disability.

Most disability insurers require you to apply for and appeal (if you are denied) for SSDI benefits at least once. It’s in your Plan provisions. If you do not do this, in most cases, the disability insurer may reduce your monthly benefit by an “estimated” amount for any expected SSDI award you receive, or are entitled to receive.

Also, most disability insurers will ask you to sign a “Payment Option Form” which asks you to agree to one of the following: (1) allow the company to reduce your monthly benefit by an estimated amount in anticipation of receiving a SSDI award, or (2) you do NOT want to receive a reduced benefit, but agree to return the SSDI lump sum to the insurance company when you receive it.  Most claimants choose option 2 because they need the money in the short-term, but please realize when you sign the payment option form agreeing to “turn over” the lump sum, you may be obligated to actually do it. Some disability insurers “drop the ball” in chasing you for this form, others are emphatic about it.

Since Unum Group is the largest group disability insurer, I will describe their internal SSDI repayment process first, then move on to some of the others, such as The Hartford. UNUM’s policies generally say they will not reduce your monthly benefit unless you do not, or refuse to apply, or first appeal for SSDI.  Intake clerks send out the “Payment Option Form” for you to sign. UNUM’s management has many internal review processes which “track” the claims handlers’ success in getting you to apply for SSDI.  If your original application is denied, you must appeal. If you are denied at the second level of application called “reconsideration” you must appeal, and UNUM may refer you to Genex, or other third-party advocates.

Genex assistance although sold as “free”, isn’t free. Genex will appoint a paralegal to assist you with further appeals (ALJ), and if awarded, Social Security will reduce your lump sum by 25% and give it to the Genex attorney, so the service isn’t free. Today, following the money may be difficult since what entity pays what other entities for advocacy is always in question. DCS, Inc. never recommends third-party SSDI advocates since they do not represent you, the claimant, but insurers who are probably paying for their services.

Because Social Security can take up to a year or more to obtain, there is a period of time when UNUM is paying you a full monthly benefit. When you are finally awarded SSDI, retroactively, some or all of the lump sum money awarded to you by Social Security should be returned to Unum in accordance with your signed Payment Option Form, if in fact you signed one. Remember, you only owe Unum an amount equal to your social security award for the same periods of time you were paid by both Unum and Social Security.

Unum’s policy for repayment is to receive a lump-sum reimbursement. They want their money in a lump-sum, and expect you to send it to them as soon as you get it. Unum has long since lost its patience with claimants who refuse to pay back money they promised to repay. New Payment Option Forms requiring claimants to agree to asset liens are now being used.

Claimants will also begin to receive phone and written communications instructing them to send overpayments as soon as possible. Typical wording might say the following: “Please send us the total amount of the overpayment within 30 days. If the overpayment is not received within 30 days, we will reduce your monthly benefit to $0 until the full amount has been recovered.”

Although Unum doesn’t advertise the fact they are willing to make SSDI repayment deals, they will work with claimants under hardship circumstances. Unum still prefers to recover the amount of the overpayment within 12 months. So, they ask you to agree to reduce monthly benefits by 1/12th of the amount of the overpayment. Some people can afford to do this, others cannot.  “Deals” for repayment of the SSDI overpayment are made through the FSU (Financial Services Unit) and not the claims specialist as a general rule. My advice is to immediately pay back the money insurers “front you” while waiting for SSDI, or make the best deal you can for a monthly benefit reduction.

All disability insurers encourage claimants to apply for SSDI benefits, chase them for repayment of the lump sum award, then consider claims for denial at the 24th month. I know this sounds like an impossible dichotomy, but the Multi-State investigation results instructed Unum to place more weight on Social Security determinations due to past unfair claims practices in denying claims once SSDI has been awarded.

Do insurers really consider and accept SSA’s decisions? Of course not. In fact, Unum’s scam is to require an IME and then reject SSA’s award decision, “…since we have new information SSA didn’t have at the time benefits were awarded.

One thing to keep in mind is that if there is a provision in your group policy allowing the disability insurer to reduce your monthly benefit by primary and family social security, your insurance company is entitled to any amounts owed. It is a matter of contract, and until the laws are changed, your employer buys certain policy provisions from the insurer, and employees must abide by the provisions agreed to.

My best recommendation for all employees covered under the employer’s group LTD plan, is to obtain a copy of your “certificate” or original LTD policy while you are still employed, and ask questions until you thoroughly understand what will happen when you have other income. Social Security may not be the only source of other income that may reduce your monthly LTD benefit.  As a consultant, I am surprised everyday when claimants tell me, “…I didn’t know…. I didn’t know…”

All middle-class working Americans should know well in advance what the provisions in their Plans allow long before it is necessary to file a claim. This relates to ALL provisions of the group LTD policy, not just those affecting SSDI and offsets for other income. If you haven’t already obtained a copy of your Plan, please do so now, and read the provisions carefully.

In summary, here are my recommendations:

Obtain a copy of your group LTD policy as an employee and understand all provisions, particularly those outlining obligations regarding applications for SSDI. As an American employee, you have an obligation to yourself to completely understand your LTD policy and how you and your family may be affected should you become unable to work. After all, you should know the net amount payable under the policy.

Be cognizant of what you are signing and agreeing to. If you sign a Payment Option Form and agree to an unreduced benefit with the promise of paying it back, you should be willing to live up to that agreement and pay it back. Far too many claimants want to receive 100% of their benefit while waiting for SSA’s decision, but then refuse to repay it back when benefits are received.

I hope this information will help you make the best financial decisions for you and your family.

Good luck.

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Just A Surveillance Reminder – Memorial Day

We are roughly two weeks away from Memorial Day, the holiday of picnics at the lake, home barbecues, and road trips. Please remember that insurance companies will be out, looking for those who exceed their medical restrictions and limitations.

This is no joke. Please be mindful of what’s possible, and damned near likely. Remember, thinking “I don’t do anything wrong” is not a strong defense. It’s not what surveillance “sees”, it’s how the insurance company misrepresents it to prove work capacity.

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The State of Fibromyalgia and Lyme disease Claims Today

Several decades ago, physicians were still prescribing morphine drips for insureds diagnosed with Fibromyalgia. Other physicians recommended their patients to “just get up on the treadmill and exercise, and you’ll be fine”. The disease abbreviated, FMS, was eventually defined as a “syndrome”, which is a series of undefined symptoms, not identifiable, credibly originating in a person’s head and frequently said to be a mental disorder.

Over time, FMS was officially named a “two pronged disease” having both physical and mental components. Changes to the DSM (Diagnostic, Statistical Manual) supported the idea that FMS had significant mental components that required treatment; and, of course, insurers required both physical and mental counseling as “appropriate treatment.”

Today, Rheumatologists are reluctant to sign off on permanent disability for FMS since they don’t really believe FMS as a physical disease really exists. Over the years, insureds have become programmed into thinking they do have FMS, and that it never goes away. Insistent insureds often convince their physicians “they have what they say they have” and treatment is given, including pain medications.

Fifteen years ago the CDC outlined specific criteria that must be met before a diagnosis of FMS can be made. (Look these up on the CDC website.) Exercise and remaining active is still part of the treatment for FMS, but to be honest the “fad” of having FMS has significantly diminished over the years. Nevertheless, FMS is still a sticking point for disability insurers and claims are frequently translated into mental and nervous limitations of 24 months, or self-reported classifications, also limited to 24 months of payments.

Lyme disease claims have also significantly decreased in number due to the new positions taken by insurers to limit benefits. In the past, Lyme disease was largely diagnosed by clinical examination of the red ring produced by the tick bite. Again, many insureds were so certain they had Lyme that physicians, too often then should have been, went along with their patients’ diagnoses and engaged in some of the most outlandish harmful treatments.

Two of these treatments actually caused harm, including IV antibiotics that were administered without end. This type of treatment destroyed the patients’ livers, and the bariatric oxygen chambers were freakish to say the least. Physicians taking the cautionary route prescribed herbal alternatives that alleviated some symptoms, but never got rid of the bacteria.

Finally, the medical community including state licensing departments had enough and threatened to take away the medical licenses of those physicians still prescribing the above treatments for their patients. In fact, they did remove a few medical licenses of the most prominent and well-known Lyme physicians. Since then, there has been a substantial decrease in the number of diagnosed Lyme cases.

Today, it is generally recognized that unless a patient has a positive CD-57 or Western Blot within 30 days of diagnosis, he/she does not have the disease. Even with positive Ig testing, the patient is given a 6 week trial of antibiotics, after which it is concluded the person no longer has Lyme. Late-stage Lyme is no longer accepted as a major cause of long-term disability.

There are still insureds out there insisting they have FMS, Lyme, and, I’ll throw in Chronic Fatigue here as well. Physicians are at times confused as to how to treat these people. Absent specific diagnostic data, physicians usually throw in “well, it must be multiple sclerosis”, and brain MRIs are ordered, and an occasional spinal tap is performed, still with no evidence of lesions or MS. Disability insurers, all too often, opt for the DMS-5’s definitions of somaticized disease (all in your head), and will limit benefits to 24 months, if they pay at all.

These diseases have evolved a long way from “morphine drips” and IV antibiotics. FMS and Lyme Disease are often misdiagnosed, and the real cause of impairment is overlooked. In any event, FMS and Lyme disease are no longer considered cause for long-term disability.

Now, someone out there is going to write me to say that they’ve had FMS or Lyme Disease and have been on claim for 10 years. Yes, I know there are always exceptions, but in general, disability insurers are still identifying FMS and Lyme as potential somaticized complaints.

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Manage Assets NOT People – Thought For The Day

One of the most profound lessons I learned in my early career came from an Assistant Professor teaching Introduction to Business at a two-year business college. As the Dean of Faculty, I was auditing/reviewing one of his courses, and I’m glad I did.

The lecture for that day involved explaining the the word MANAGE and that it was a “thing” word. A person manages their checking account, or manages their careers. Therefore, one can only MANAGE things, but not PEOPLE. “People”, he claimed are LEAD, not MANAGED.

The rest of the lecture distinguished between the old Henry Ford concept of “micromanagement” vs. the new concept of “management by objective.” Interestingly, the professor said that statistics proved companies using “management by objective” were three times as profitable as companies still micromanaging their people.

Using myself as a Consultant for example, my job is to provide leadership to insureds and claimants on how to manage their claims. My objective is not to manage insureds, and it is never a good idea to allow my clients to manage me. Disability is a people issue, and claims are a thing issue. And, in the last 25 years, it has always been my experience that “best laid plans” to manage people in this profession, either way, usually fails. My job as a Consultant is to be a LEADER and show insureds how to solve problems and manage claims to a successful end. Together, we manage claims, not people.

I hope this gives you something to think about for today, and how you can be an inspirational leader to your family, and social groups. Have a great day!

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As The Saga Continues “What Do I Do Now?”

“After maximum duration” claims continue to call DCS looking for answers as to what to do for income when claims end at 65/67. Actually, a few of the stories are pretty tragic, and my heart goes out to those who will be left with nearly half, or nothing, to live on.

Take the case of the prominent health professional with a benefit of $10,000/month who was under the impression from his employer’s website that his benefits would end at age 67. In reality, his benefits recently ended when he turned age 65, and he only found out about it when checks began to bounce from his checking account.

It’s a big mistake, by the way, to continue to go to insurance portals and websites for accurate information. Employers continuously update and change their Plans. For this insured, reassurance of benefits to age 67 was ill-gotten since he either forgot, or didn’t know, that the policy adjudicated is always the policy in force as of the date of disability. Since he had a date of disability about 10 years ago, his Plan was a much earlier contract limiting benefits to age 65.

Thinking his benefits were safe for another two years, this insured did not have a Plan B, and never planned what he was going to do when benefits ended at age 67. In other words, he would be in exactly the same situation at age 67 than he is right now. It is extremely important not to take disability benefits for granted at any time. What do people do when insurers deny their claims out of the blue?

Without proper financial planning, insureds are setting themselves up for a potential disaster now, AND when benefits reach the maximum duration. It is absolutely necessary for insureds and claimants to gather information about their assets and potential future earnings capability now, rather than face financial challenges in the future.

Life always has options. But, it gets a little sticky when there his only one option left. If you’ve been taken by surprise and find yourself at age 65 with no benefit, there is only one option left – solving the problem.

Why do you see so many elderly people bagging groceries at the store? I actually stopped one day and asked a rather elderly gentlemen why he was still working. He explained that he was supplementing his SSDI income. Since SSA allows an individual receiving SSDI to work up to a maximum earned income of $2,590/month in 2024, he needed the extra income to supplement his SSDI. The $2,590 is called “SGA”, or Substantial Gainful Activity. Income over this amount is considered toward a “TWP”, or Trial Work Period. (If you want to know more about this, please go to ssa.gov and read the “Redbook”.)

My point is, however, that working to supplement SSDI is “an option.” Clearly, the above health professional won’t be able to make-up for $10,000/month loss, but with a down sizing of lifestyle, he and his family would adjust.

There needs to be a Plan B, folks. Sooner or later your disability benefits will cease. My suggestion is to go to your Plan or policy today, and find out when your benefits will end. Then, consider the possibility that your claim could be denied, and start planning. I can’t tell you what, or how to plan since very person’s situation is different. But, you have to have something in your back pocket eventually. Do it now, and be prepared.

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What Is Your Plan B?

Whenever I start writing about “planning” my readers tend to throw rocks at me. I get it, planning ahead is not something people necessarily want to talk about. Although I was writing about  having a Plan B many years ago, the absolute urgency of doing it now is an even more of a priority than ever before.

There are many reasons why insureds and claimants should have a Plan B. Just the other day I got a call from someone asking me to follow-up since his check was late. His wife apparently had gone to the grocery store and wrote checks, but no benefit arrived.

Upon checking, it turned out this insured had received a letter back in February (he didn’t pay attention to), informing him that when he reached age 65 his benefits would end. And, so they did. The insured was under the impression benefits would be paid to age 67, or, at least this is what the insurer’s website said.

Disability insurance products are unreliable because it is the insurance company that decides whether you get paid or not, or whether or not you’ve met the criteria in the policy. In other words, benefits can be here today, and gone tomorrow. What will you do then? If benefits end at age 65, will you be able to live on SSDI? Do you have tangible assets that can be used to pay your bills?

It would seem to me that those receiving disability benefits would put having a Plan B a priority on their to-do list. It’s almost as though there is a belief that the disability benefits will ALWAYS be there, so there is no need to plan.

We all know that’s not true. Very few people can actually live off of SSDI/SSR these days. I recommend that insureds sit down with a pencil and a piece of paper. Draw a line down the middle and list all income on the left and expenses on the right. Then cover the income from disability benefits, and reconsider the list.

Here are a few things to think about.

  • Will I be able to pay off any existing mortgage and/or credit card debt before my policy ends?
  • What tangible assets do I have that I can depend on to pay my bills? (SSDI, dividend and interest payments, annuities etc. land, personal property.) What other personal property do I have that I can sell?
  • Do you know where your state resources are, and what the criteria is in order to be eligible? (Food stamps, state aid, free health care etc.)
  • Will it be possible for me to live with other relatives if my claim is denied or expired?
  • Do I have insurance policies I can cash in or receive an advance on?
  • What if, due to national emergencies, SSDI and SSR go away? Where will your resources come from then?
  • Does your state support free medical care for the elderly?
  • Can I pay off my car and live debt free?
  • Should I be prepping and putting food and water aside?
  • What am I able to do for work? Part-time? What are my current skills and should I be using this time to learn a trade of some kind?

These and other circumstances should be considered when putting together a Plan B. It’s pretty scary, I know, but there must be some sort of Plan B written down so that life can continue when disability funds go away. And, they will go away at age 65-67. What then? Those with Lifetime benefits aren’t protected either. What if the insurance company goes out of business?

Please don’t allow yourself to be caught off guard without your own personal Plan B. Disability benefits are unreliable, and you want to make sure you have something in your back pocket.

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Unum Claim Alert!

Although I’ve been informing the public about the inefficiency of the insurance industry, Unum remains an excellent example of the “goof ups” that occur.

In the last two weeks I’ve received many calls about Unum sending out letters alleging that only the “Physician’s Statement” was received and nothing else. Despite insureds’ sending in multiple page patient notes etc. Unum continues to allege it only received the Attending Physician’s Statement. When I called in, however, a Customer Care rep was able to verify that ALL of the information sent was received.

This is scary as hell for people thinking their information was not received. In one incident, both me and my Client sent and faxed the information, so Unum actually received it twice. My Client had fax verification and I sent with Signature Confirmation. Unum’s recent letter claims that only the APS form was received./p>

I had heard some time ago from a Unum claims handler that the Columbia, SC communication center was in a chaotic mess. This new situation, though, of alleging non-receipt of the APS, but nothing else, may mean that the communication center is only scanning in the APS and nothing else. Unaware claims handlers are sending out letters with false information. THIS NEEDS TO STOP!

Along these lines, I recent encountered a claims handler who absolutely could not speak English. I had to ask to speak to someone else “who could speak better English.” Unum is still using people all over the world remotely to manage claims. They are largely untrained, and as I said, unable to speak understandable English.

In addition, the new English-speaking rep was unable to locate an Authorization submitted to the file in 2017. This tells me that the claims handlers DO NOT HAVE access to the entire file, but only deal with maybe the top 20 or 10 pages. This also supports my prediction that the claims handlers are just “pushing paper” and are following protocols designed to obtain paperwork, have it reviewed, and then deny the claim. It is doubtful that any Unum claims handler today would have the know how to target and create an illusion good enough to support claim denials.

So who is it that’s denying claims you might ask. I suspect it’s the old guard English-speaking managers who are still with the company, attempting to risk manage what they can get their hands on. Add-in third part paper chasers and the whole process of updating claim files become a chaotic mess.

As it always has in the past, Unum’s mistakes and errors now place insureds and claimants in positions of having to take the responsibility of risk managing their own claims. Insureds will either know how to do it, or they won’t; but, at the end of the day, the result is going to have the same victims — insureds and claimants.

Someone said to me yesterday, “Please take care of this. I have cancer and I can’t handle all the paperwork and constant re-faxing.” And, of course, I will help, but it’s important for Unum insureds and claimants to understand what they’re up against. It’s getting really bad out there folks, so be mindful, and try to take care of business as best you can.

If the same things are happening to you, please send me an email and let me know what kind of a mess Unum is claiming. I may share some of your experiences, anonymously, of course, with others who may be in need of communal support.

DCS@metrocast.net

 

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It’s Important To Pay Attention To Changes

In the last six months or so I’ve been writing one article after another about the changing disability claims process so that insureds know how to handle things. Still, I am receiving phone calls from insureds and claimants sharing their anxiety when things aren’t going as they expected.

I’m not really sure what else I can say that insureds would listen to, but I’m going to give it a shot.

Post-COVID, insurance companies have made internal changes to their claims process that prioritizes paper chasing and reviewing.This is achieved by remote (worldwide) resources, third-party paper chasers, with a small management holding it all together. As a result, insurers are more inefficient than ever in the following ways:

  • Reorganization to “team” management of claims instead of one person. Unum, for example only signs letters now on a first name basis. This is to prevent assumptions that this one person is managing your claim. If the objective of “the team” is to tussle paper, then there is no point in having just one person have access to your claim. You never know.
  • Significant lack of personal contact with any member of the team “touching your claim.” Customer service is largely non-existent, therefore, this is not the best time to be calling insurance companies every day. ( You shouldn’t do this anyway.)
  • Third-party paper chasers are harassing treating physicians until they get what they want. You doctors may begin to complain and ask for help to stop the nuisance calls.
  • A dedicated concentration of getting requested paperwork, surgery and consultation dates, contacting secondary doctors, insisting they can’t pay claims without a certain piece of paper, and any other claim protocols directed by the higher ups.
  • Insistence of speaking with you on the phone. Don’t get pulled into this one, and keep asking for all communications in writing.
  • Timelines are non-existent. Letters are sent out two weeks before they arrive, or so the story goes. Always date and initial paper communications (envelopes) on the date received.
  • Forget ERISA. 99% of claims handlers do not know what that is and timelines mean nothing. No one is enforcing ERISA these days.
  • Process Administration errors. Letters you receive don’t make sense; it’s almost as though they are written to someone else. (Untrained claims handlers make many mistakes!) I wouldn’t take any letter communication seriously without verifying what it’s about.
  • Loss of paperwork, or delayed posting from communication centers to claims handler desktop. I’ve found the most accurate verification of receipt of paperwork is with customer care, if you can get someone to talk to you.
  • It now takes upward of a year to get an appeal decision once a claim is denied.
  • Claims handlers are only dealing with “recent” paperwork, probably don’t have access to your entire claims file, and won’t remember any last conversation you’ve had. For example, if you signed Unum’s “Optional Authorization to Provide Information to Third-parties”, on which you indicated “written communications only” at the beginning of your claim, forget it, no one is going to see that paperwork today. That’s why they are still calling you.

So, what to do about it you might ask? What’s the new strategy? Well, I can’t tell you everything because as a Consultant I offer services to manage it. But, here are a few tips.

  • Stop making all those phone calls! You’re never going to get the same person, and you can’t rely on what anyone tells you. Understand very clearly….these claims handlers aren’t trained to do anything else but chase paper.
  • Document everything in writing. Send faxes, write letters, request information be placed in your file.
  • Try to stay within your given deadline to submit update paperwork. If deadlines can’t be met, send a fax informing when the paperwork can be sent in. Don’t call and ask for an extension, it won’t be documented.
  • Date and initial all communications received.
  • Communicate only in writing. No portals. Emails are OK if you save them.
  • Keep a journal of all actions taken on a claim.
  • Turn down the anxiety. For example, if you receive a letter sounding like it applied to someone else’s claim, send a fax and ask directly what you wanted to know. Be prepared emotionally for the negligence and inefficiency. We know it’s going to happen so just deal with it and be done.
  • Start filing internal complaints again. Get your concerns on the record. The complaint itself won’t go anywhere, but your letters will go into your file.
  • Download only the most pertinent information to your impairment and ask that it be placed in your file. Don’t overload, just make sure what you add to the file is relevant to your medical condition.
  • DON’T POKE THE BEAR! You can’t argue with someone who doesn’t know anything about your claim. Work with the system, albeit as bad as it might be, to achieve what YOU want. Avoid proving any issues or creating “red flags.”
  • This is not the time to push the envelope on medical restrictions and limitations. Surveillance is the major tool of  choice insurers use to “Gotcha!” Remember, it’s not what they see you doing, it’s how they INTERPRET what they see you doing. “Seeing is believing” and you can’t take it back. STAY OFF OF SOCIAL MEDIA. Just don’t do it!
  • Remember Murphy’s law? If you think it can’t happen to you, well, you might be surprised how often the worst things can happen to people who think it can’t happen to them. It can happen, and it eventually does, if you don’t pay attention to what you do and say. If you get on the phone and OVER SPEAK  your claim, (a nice way of saying “you talk too much”, you may regret it later.

I really hope that this blog post convinces you to pay attention to what’s going on with your claim. This information is extremely IMPORTANT, when it comes to managing disability claims. I know there are readers out there who are trying to manage claims themselves. The worst things you can do is to get upset, overreact, talk too much, and let fear take over to the point you do exactly the wrong things.

To be clear, you’re going to be dealing with complete failure of disability insurance companies to provide insureds and claimants with a fair and equitable review of their claims. Paperwork will be lost, “We didn’t get it” is now a famous capstone statement. There will be no one to complain to.

Finally, I want to leave you with this message: THEIR MESS ISN’T YOUR MESS. While it’s not your responsibility to clean up the errors, it is important to CORRECT errors that affect your claim; and, you can do that by putting the facts in a fax or letter that goes into your file. Forget the phone calls, you are wasting your time!

In two decades insured’s have gone from being victimized by “STACKING THE DECK AGAINST YOU” to “52-CARD PICK-UP”, literally. If you have any questions, please feel free to give me a call. I’m here to help.

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Topics Of Interest – Short – Shorts.

One of the major claim management errors insureds make is NOT realizing, “the process isn’t YOUR show.” In other words, insureds and claimants do not call the shots, nor can they tell an insurance company what to do. Oftentimes, this is quite humbling to some insureds who think they are the boss. Ranting, insisting and contacting the claims handler over and over again is not going to get your next benefit check released.

While we can’t control what an insurance company does, we clearly can control what WE do. And, there are claims strategies DCS Clients use that achieve the goals and objectives that benefit them. But, I see it all the time – those who think the insurance company has to do what they say, and are quite surprised when they don’t. Instead of trying to constantly “defend” a claim, think of credible ways to “promote” the claim, and come across as the “good guy.” The narcissists have to take a back seat on this one, and change their tactics in order to have paid benefits long-term.

Third-party paper chasers are eternal thorns in the backsides of most insureds. Not only are they aggressive to the point of harassing, treating physicians are screaming out for help to keep them from calling every day. Here are some things to remember about the “paper-chasers”.

  • Companies such as Release Point, Claimify, MONY etc. have no authority over the decision-making of claims. They do only one thing –chase paper, namely patient records.
  • Paper-chasers have a scheduled process that THEY WILL NOT CHANGE. Therefore, it does no good for insureds to contact the chasers looking for relief, understanding or approved delays.
  • Always deal with your claims handler NOT a paper-chaser. If your physician is being harassed, send a fax to the claims handler saying something like, “please inform Release Point (example) to cease and desist from contacting my physician. You could even withdraw your Authorization, but I would only do that in extreme situations. You have the right to provide any requested records yourself, and I’d do that.
  • Don’t be fooled. Paper chasers often send requests on the letterhead of your insurer to make your doctor thinks it is coming from an insurance company. Just always deal with the claims handler.

Most of the written letters you receive are “canned templates” chosen from a Window drop down. The Claims Handler is supposed to “edit” the wording to fit your particular claim, but they often don’t have time to do so. Therefore, don’t be surprised if you find a lot of gibberish in long letters that don’t even pertain to you.

A good example is the Independent Medical Evaluation notification paragraph that is appearing in most Unum letters. The Multi-State Settlement requires the notification, and so there is a “template” for it. Some Unum claims handlers add it to their letters, others do not, but in most instances it seems out of topic for most people’s letters. While employed, I did not like the fact that I was forced to sign my name to letters I didn’t write.

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Why Do You Give Me The Bad News?

I was speaking with one of my clients recently who shared with me that I seem to always report “bad news.” “It was quite frightening”, she said,” learning about all the bad things insurers are now doing.”

From the perspective of insureds, I’m sure hearing all about the insurance industry, and it’s bad faith can be frightening.” But, in the long run, NOT knowing, is a lot worse.

I would like to take a moment and explain my rationale for communicating the truth about what can happen to unfairly deny disability claims. To do that I have to explain a little bit of the history of UNUMProvident, which I’m sure was used as an example by many other insurers. I’ll give you the short version, I promise.

Two decades ago, disability insurers were operating without a great deal of constraint. When it was discovered that Harold Chandler(Provident and Paul Revere), and his henchmen (1999) were universally engaging in bad faith, the whole system went crazy with disinformation, particularly the Internet. Insureds were posting so much information a man by the name of Jim Mooney started an online newsletter to help straighten it all out. I had a column called “Inside UNUMProvident” where I shared as much information about the claims process as possible.

Anxious to make money, and lot’s of it, attorneys took on cases they knew absolutely nothing about, furthering the disinformation. It became commonplace to tell insureds “exactly what they wanted to hear” in order to make money on the volumes of claims that were denied.

It was a mess, to be sure. Those who fought the system like Judy Morrison, Jim Mooney, and law firms such as Andersen, Kill and Slick (NYC) were pegged by the opposition as traitors to the industry. Judy, by the way, was an insured whose claim was denied by Unum. She went to court pro se and won. Later, she killed herself, likely a result of her medical condition of bipolar disorder.

Years later when I started DCS, Inc.I wrote the company philosophy as “imparting information to insureds and claimants equal to that of the insurance companies targeting their claims.” It was only fair that insureds should be knowledgeable about what was going on. Although many thousands of insureds, over two decades, have benefitted from having better information, including their attorneys, the message has not been universally well received.

A minority of insureds do not want to know “bad news.” As the messenger, I am “dropped like a hot potato” as the bearer of bad news. In years past I’ve often recommended to insureds that they write out a family Plan B; but, stopped writing the articles when I was criticized for it. Even today, I wonder how many insureds have a Plan B for added income when benefits end at age 65-67.

My opinion has always been that when it comes to managing disability claims, “knowledge is power”. If WE know what the insurance companies are doing, WE also know what to DO ABOUT IT. I have never subscribed to the notion that I should tell insureds “what they want to hear.” I had a client a few years ago who walked away because “I wasn’t giving her the nice, kind, friendly, positive opinions” that she expected. I have found that people call me because they know they will get the “straight story”, and on that I’ve built my reputation. Likewise, there have been a small number of people who hired me to do what they tell me do, and for those of you who actually know me, understand that didn’t work out well at all.

While I understand that there are some people who have anxiety when I speak the truth about disability claims, there are far more people who benefit from knowing what could happen, and what we’re going to do about it.

Finally, thinking rationally, there is often too much money involved with disability claims to ever “tell insureds what they want to hear”, and I will never do that. Good or bad, insureds and readers will always hear the truth about the process from me. I don’t try to sugar coat the message, but I can suggest solutions to any claim crisis that may come up. And, that’s the truth.

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Topics Of Interest – Short Shorts

Insurance companies have resurrected using what I refer to as “third-party paper chasers. Please Point is just one of the companies who are hired to chase medical paperwork for disability claims. Clamify is another one. These companies have always harassed insureds and treating physicians, often making phone calls to their offices everyday, sometimes more than once. Physicians are getting sick of it and are trying to find alternatives as to what they should do.

First though, let me explain that these third party chasers have no authority over your claims. They are administrative personnel “who chase paperwork”. They make no decisions, and yet they are driving people crazy. They often use “Unum” letterhead (or another insurer) to make them look credible, but in the end, they harass and make calls to the point that normal medical records requests become much more difficult than they need be. From their perspective, I guess that’s the point.

If you are being harassed by any number of third-party paper chasers, notify the claims handler that you will provide the records yourself and to “cease and desist” from contacting your physicians. Always deal directly with your claims handler, never Release Point because you won’t get anywhere. One time when I contacted Release Point I was told,” this is our protocol and how we do things.”

Remember in prior posts that I informed you insurance companies were going back “to their old sneaky ways?” One of the ways they are doing this is to request medical “proof of claim” from periods way before you claimed disability. If there are pre-existing issues with your claim, insurers are entitled to go back three months prior to the Effective Date of your Plan or policy.

For IDI claims, if there is a Contestability issue, insurers could legitimately ask for paperwork before your Date of Disability. Beyond that, they have no reason, or right, to request patient notes way back in time. A good example, is Guardian requesting records back to 2018 for a date of disability in 2020. No pre-existing or Contestability issues. This is unreasonable nonsense, and you don’t have to honor those requests.

If you are receiving insured’s correspondence in the mail, please remember to date the envelope on the day you receive it. The 30-45 days begins as of the “day of receipt” and since insurers are sending out letters as much as two weeks after the date of the letter, you need to initial and date the envelope as to when the mail is actually received.

In keeping with this point you and your physicians have 30-45 days (ERISA) to provide requested “proof of claim”. We do not allow insurers to operate outside of the Plan or policy contract.

These are just a few of the questionable claims practices to watch out for. I’m sure there will be many others as insurers get their risk management together again.

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Unum Claim Denials -“Bad Apples, Again”

 

As my readers are aware, I’ve been writing articles about insurance companies and recent tendencies, particularly Unum, to deny claims using “retro” or “old” unfair claims practices. On Friday, I had the opportunity to review two denial letters, both ERISA claims, one of them with an appeal denial. What I surmised all along is actually true; and I’ll give you reasons why I say that.

As a claims consultant with 25 years experience, it wasn’t all that hard to identify how Unum is performing reviews using methods that were expressly forbidden in the Multi-state and California Settlement Agreements. One of the four claims practices pinpointed by the Multi-State Review Commissioners was the “over-reliance of internal reviews and reports”, specifically those in conflict with medical assessments communicated by treating physicians.

Specifically, the RSA (Regulatory Settlement Amendments Section B3) compel Unum to give considerable weight to the opinions of physicians and declares that Unum may NOT discount physician opinions unless they are outside of realm of acceptance of modern medicine. Therefore, Unum is required by the RSA to stop making decisions based solely on their own internal reviews.

Well, don’t count on it. In both of the claims I reviewed, Unum pushes the credentials of its reviewers, and even goes so far as to have second and third internal reviews if there is any disagreement. It’s as though Unum thinks that more than one biased internal review is better than one. Twenty years ago a physician was regarded as “super qualified” if he/she was Board Certified, but today physicians are already Board Certified by the time they graduate medical school, or finish Internships. It’s not big deal anymore and “Board Certified” physicians are no more experts in their fields than any other physician.

Second, both denials use “Occupational Review” to document “occupation as defined in the national economy”. It is true that ERISA Group Plans do not insure “the job”, but only the “occupation” as it is defined in the national economy. CRCs (Certified Rehabilitation Councilors) use Department of Labor outdated data bases to obtain capacity definitions “as defined in the national economy.” Of course, not ALL occupations are specifically defined, therefore, Unum uses its “discretionary authority” to put the square peg in the round hole to justify thousands of denials.

To be honest, I had evidence 10-15 years ago that many ERISA judges threw out the old “national economy” defense and required Unum to use occupational information more in line with the claimant’s actual job. Unum’s use of the occupational back-up to deny claims may very. well turn out to be as unsuccessful as it always was. In any event, it’s back on the table and probably will be misrepresented by “any occupation” reviews at 24 months.

The appeals denial is very strange, since the policy adjudicated was an old XL or XLL policy that was in force prior to the CDC Series in 2000. These policies are really the reason why the infamous “Blue Memos” were circulated, because the older versions of Unum Group Plans were way to general, and didn’t give the company the contractual authority to deny claims very well. So, Unum published the CDC series of ERISA Plans clearly defining what it could and could not do. Interestingly, the old XL and XLL polices are indeed ancient and I can’t imagine anyone currently at Unum knowing how to adjudicate it. The Plan itself contains no “national economy” definition, even though it was cited in the appeals denial.

In summary, Unum is using its own internal reviews as the basis for denials; it is ignoring opinions of treating physicians; the company is using “occupational reviews (internal) to back up denials; and, second and third internal medical reviews to make it appear the denial is credible. In truth, no physician at Unum will ever disagree with any other Unum physician, so having more than one review isn’t really contributing to the denial’s credibility.

Unfortunately, I predict more unfair claim denials from Unum. In my opinion, UnumProvident and Unum Group never did comply with the directives of the Multi-State Settlement Agreement other than reassessment of claims.

I have said many times that the best appeal in the world is not to get denied in the first place. There used to be a saying at Unum, “Go for the biggest bang for the buck”. This is not the time to sit back and think you have everything under control. Be smart, and find out how to manage your claim accordingly.

Unum has always been the bad apple in the barrel. It’s claims practices corrupt every other apple in the barrel, so insurance companies other than Unum are all on board with the same old claims practices.

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Claim Fear – Why Am I So Afraid?

I haven’t written about “fearfulness” in quite some time. Over the last few years, it seemed to me that most insureds were dealing with the anxiety associated with their claims fairly well, and I hadn’t felt the need to mention it. However, over the last several months I’ve been hearing insureds’ fear again –  fear that could potentially deny them the benefits they desperately need.

I suppose one could say that fearfulness associated with disability claims is normal. There is a sizable portion of uncertainty with managing disability benefits, and it’s within the set of “normal feelings” to be afraid. And, that’s true, but only to a certain reasonable point.

I’m sure that the “fear” I’m speaking about is 70% due to having to rely on an outside third party for financial support. No one wants to be left without the funds to pay bills to continue to support the family. Not having any money is indeed something to be fearful about, but if “being afraid” causes you to react, say, and do things adverse to your claim, then it is contraindicated and insureds need to be extremely mindful of their reactions to requests etc.

First, fear often causes insureds to accept, say, and repeat inaccurate information. The Internet is NOT a credible source of information because every one seems to have a sad story about their claims. Believing unsubstantiated Internet chat groups etc. is a huge mistake and keeps you fearful.

It is NOT true that having someone helping you with your claim creates red flags and brings suspicion to your claim. It is NOT true that if your update paperwork must be late, your claim will be denied. If you write a letter to the claims handler in advance asking for an extension, it is usually granted. It is NOT true that making a claims handler angry will result in a denied claim. Insureds who are fearful usually manage their claims based on false and inaccurate information they couldn’t possibly defend.

Second, insureds who are fearful will generally give up any and all information about themselves even when they are not required to do so because they believe if they do, benefits will be paid. This is entirely false. Imagine that the person on the other side of the phone is deliberately attempting to deny your claim while at the same time you are actually providing proof of work capacity because you think it will keep your claim paid. You are required to provide proof of claim, financial and occupational information. You are NOT required to provide a road map for your gardening, walking your dog, weekend trips with grandchildren. Claims handlers are NOT your friend and shouldn’t be treated like one.

Third, insureds who are afraid usually check the insurer website portal more than once each day. This is a huge mistake. I have seen denial letters cross my desk alluding to the fact that an insured checked the website portal 10 times per day, and “if you can do that, you are demonstrating work capacity. Nevertheless, I’ve also been told website portals have “tracking trojans that track insureds every where on the NET. Just so you know, website portals are not always up to date, and they are NOT downloaded and provided to attorneys looking for an unsanitized file in cases of litigation.

I’m sure you get the point. “Fearfulness” causes claimants and insured to do and say what they normally would NOT do or say. It’s also true that being fearful and having anxiety about a claim does NOT help your medical condition or impairment get any better.

So how can you identify the level of your fear? Please see the list I’ve experienced with Clients over the years.

  • Checking a website portal more than once a day just to ease your anxiety that everything is OK with the claim.
  •  Experiencing anxiety, shaking, stomach pains, insomnia, nervousness, and fearfulness just before benefit checks are due. Once the money is received, insureds generally settle down until next month when the anxiety cycle begins again.
  • Insureds are afraid to open mail received by insurers. Sometimes the letters are set aside until insureds can work up enough courage to actually open the letters.
  • Calling the claims handler frequently just to assure yourself everything is OK with your claim. (Actually, this causes an “internal red flag” you really don’t want.) Calls to claims handlers should NOT be made frequently.
  • Insureds are unable to manage the household, pay bills, or take care of children just prior to the benefit due date. Frequent arguments with spouses also take place until the benefit check arrives, then all quiets down.
  • Giving an insurance company every thing they ask for even when it is unreasonable or out of contract.
  • Exaggerations, such as thinking a disability insurer can take your home, and other assets from you. This can be terribly distrubing.

Again, I’m sure you get the picture. If you have two or more of these “symptoms”, you are probably very scared about your claim. As I said in the beginning, fear is a normal human manifestation to the craziness of filing a disability claim. But, there are limits that when reached can cost you your claim.

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If You Go The Attorney Route- Be Careful

Within the last 6 months or so, several people who have called (non-clients) to say they hired an attorney and they want my help because the attorney isn’t doing anything. Attorneys are retained for claim appeals, or possible settlements, but I found out today an Unum “appeal and settlement” is still unsettled more than 6 months out. Yes, I’ve heard several complaints about this, but unfortunately there is nothing I do to help at this point.

A few callers have told me that attorneys are now charging $500-$900 per hour, with fees of 40% back/40% forward to maximum duration of claim. In my opinion, these types of fee are highway robbery, but vulnerable insureds seem to think something gained is better than nothing and the attorney’s skill matches the highest fees. This isn’t true at all.

If an attorney quoted me $900/hr. I would ask to see his successful litigation files over the last two years, particularly ERISA. IDI claim files should demonstrate successful awards as punitive damages, bad faith, or censure. I wouldn’t just pay an attorney that high of a per hour fee because he asks for it. Ask for proof of successful litigation cases.

I also would never retain a nationally advertised law firm that promises the world to insureds. There are also attorneys who claim to be ERISA experts. They write books and publicize themselves as sympathizers of ERISA claimants, but yet wouldn’t take on a non-wealthy ERISA claim to save their lives. It’s all a big promotion to convince hurting insureds to agree to pay high costs to attorneys who are desperately looking for cases to their own financial demise.

Therefore, if you do decide to go the attorney route, be very careful who you retain, and make sure you check him/her out before signing on the dotted line. Attorneys are hurting just like anyone else these days and are not above taking advantage of those who need their benefits to pay bills. I’d be very careful.

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Know What You’re Eating

My readers may, or may not know, that I am an absolute fanatic, (granola head, really), about food additives and toxic food. No, I’m not a skinny rail, nor vegetarian or vegan, but careful about what goes into the food I serve my family. If you’re asking what this has to do with disability, in my opinion, I’m sure everyone has their own “eat or no eat” practices. Commercial food additives are not good for any of us, and I’m just suggesting that it might be interesting to do a bit of research as to what’s on your plate.  I only offer this information as a resource, you may be interested in.

The best resource I found on the Internet about food and body chemical additives is on YouTube. Bobby Parrish and his FlavCity company has many videos  that explains what chemicals are not good for you, and what alternatives are out there.(https://flavcity.com)

Admittedly, the alternative foods and products are more expensive, and you don’t have to buy them, but at least you will know what’s GMO and what’s not. Other chemicals are equally as dangerous for consumption

If you’re interested, please check out Bobby’s videos. He also has an app available from the App Store that scans the bar codes of products in the store and tells you whether it’s Bobbie approved for not. I have no special interest in FlavCity and no one is paying me to promote him. I have both of his cookbooks and have found them to be very informative and interesting resources.

In the end, people will eat or not eat what they want, and sometimes people do have to “pick their poison”. Doing the best you can to eat clean and  well during disability is equally as important as taking your medications. Knowing what you’re putting into your mouth is, today, more of a necessity than not.

When I write snippets like this I always have to include a waiver because someone out there is saying, “Don’t tell me what to eat!” I know because they’ve said it to me. I’m not telling anyone what they should eat, just recommending a resource if you are interested.