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Friday Q & A

Q&ALinda, can you please explain what “regular care” is?

“Regular care” is the frequency of medical consultation and treatment recommended for each impairment that is reasonable to sustain wellness, Maximum Medical Improvement, or control and treat disease. For example, Mr. X informs his insurer he is totally disabled due to depression and anxiety and is unable to do his job. He reports he sees his therapist every other month.

Consulting with a therapist every other month would not be considered “regular care” since an individual who is depressed sufficient not be able to work should be in counseling a minimum of twice a month, and preferably once a week. Quarterly visits for  mental health counseling for a disability severe enough to cause cessation of work is NOT considered regular care. Standards of care are set by the American Psychological Association and the DSM-V.

Another example perhaps would be Mr. B. who is diagnosed with chronic back pain and who consults with his orthopedic and family physician once a year. Mr. B. is also prescribed opiates for pain. Any patient who is taking narcotic, or opiates for pain should seek consultation and treatment frequently. Physicians who prescribe such medications usually make it a point to actually “consult” with their patients before renewing prescriptions for pain narcotics. Disability insurers would view yearly visits as outside of the perimeters of “regular care.”

This brings up a good point about pain management. For some, there may come a point when orthopedic conclude, “There is nothing more we can do for you” and we recommend you go to pain management. Insurers do not accept the rationale of “there’s nothing more we can do for you” when it comes to regular care. Insureds and claimants must still consult and seek treatment from family physicians or pain management facilities on a regular basis. Yearly treatment isn’t reasonable for claimants who report their pain is severe enough not to work.

Treating physicians can actually nip the “regular care” requirement in the bud by documenting, “Based on my medical treatment and history with this patient I have determined that quarterly consultation and office visits are appropriate and regular care.”

“Regular care” is objectively proven with the submission of patient notes which is why most insurers insist on requesting them. Patient notes contain records of when claimants were seen, how often he/she was examined, and outcome. Those who cannot produce patient notes (proof positive of regular care) are said “to have fallen out of regular care.”

Insureds should always keep in mind that without regular visits and medical consultation there is no disability claim.

What are Unum’s physician salaries?

This is a real sore spot for Unum management since internally it is preferable to create what I call “competition envy” among its physicians. One of Unum’s former medical directors told me that physicians are strongly cautioned not to discuss their salaries or yearly bonuses with each other. Not all physicians receive the same yearly bonus percentage. My opinion is that those physicians who deny more claims and are able to support Unum’s internal protocols are given more money as incentive. This is the one issue Unum is very sensitive about and I get the impression that if physicians were aware of the monetary discrimination, there would be internal upheaval.

In the past, I’ve said that the average ball park salary figure for Unum physicians is between $150,000 and $250,000 per year plus incentive. Realistically, Unum doesn’t allow specific information about salaries to go public even though it could be available otherwise on the Internet.

In my opinion, it’s not the amount of money Unum physicians are paid, but the fact that Unum’s physicians, or any insurance physician, parks his/her medical ethics at the door in order to misrepresent medical information in a way that supports the insurance agenda. If you ask me, insurance physicians cause harm and ignore the oath of their profession. I can’t imagine what it must be like to train for so many years to become a doctor only to trade Hippocratic for Hypocrite to benefit an insurance company.

I found this wording in my Unum claim file: “Clmt is dx with FMS and is td own occupation pending CID.”  What does it mean?

Argh….UNUMSPEAK.  It means, “Claimant is diagnosed with fibromyalgia and is totally disabled from performing her own occupation pending change in definition.” The writing means that the claims handler will pay and manage the claim until the change in definition when the “plan” to deny may change.

Poor Customer ServiceDCS, Inc. has been documenting calls from Unum insureds and claimants reporting “nasty” claims handlers and those who provide little to no customer service.

I have to admit I’m surprised to hear Unum management lost control of its “claim to fame” of providing “exceeds” customer service, but according to reports from claimants, Unum claims handlers have become tyrants and live among the “nasties.”

Whatever happened to, “Even though we deny your claim we want you to be able to say Unum is a good company?”

According to one caller yesterday, Unum’s claims specialist refused to allow her to speak and kept talking over her until she finally gave up. He chastised her for “altering” one of Unum’s Authorizations and demanded she allow for the release of her SSDI file. In short, Unum’s claims handler treated her as if she was a criminal and the worst malingerer for having filed a claim in the first place. Frustrated and angry, she finally hung up.

This is one of the reasons why DCS, Inc. continues to recommend insureds and claimants request all correspondence in writing from insurers, particularly Unum. It’s much harder for claim specialists to communicate harshly in letters, and in addition, insureds and claimants should always be mindful of creating a good paper trail. It’s a sure bet that Unum claims handlers aren’t documenting their attitudes in the official record.

Of course, there is a real cost of not providing good customer service. Public perception of Unum Group is already very poor and its conceivable that those who have to deal with Unum “nasties” will be communicating with others, even employers who buy Unum group STD/LTD plans. Eventually, new business will be lost because of poor customer service. The problem is – Unum doesn’t care.

Providing poor customer service is a departure from Unum’s traditional best practices. In fact, at one time management forced all claims handlers to sign “Customer Service Contracts” stating they agreed to provide “exceeds levels” of customer service. Communicating disrespectfully to claimants on the phone was a “performance” issue with possible termination.

Today, Unum management stands behind irate claims handlers as long as they have proven records of providing top shareholder value. (Denies more claims.) State regulators do not do “nasty” and will tell insureds they don’t want to hear it. And…..insureds and claimants shouldn’t want to hear it either!

In the end, the very best way to handle Unum’s moody claims handlers is to ask for all communications in writing. Start creating a paper trail of misconduct and save yourself from being called out on the phone.

Denied StampIt has always been very interesting to me that DCS, Inc. receives many more calls about Unum claim denials at the end of a financial reporting period than any other insurer. As we near the end of August denied Unum claimants are looking for consulting assistance with an overwhelming number of claim denials.

To date, DCS, Inc. has NOT received any phone calls from those reporting denied claims from any other insurers. It’s a sure bet Unum is up to its old tricks of targeting claims at the end of a month, quarter, or year-end in order to bolster profitability.

I can say this with some degree of certainty since I once worked for Unum, and in combination with Unum’s other patterns of practice and multiple claimant phone calls to DCS reporting unfair or egregious claim denials at the end of the month, it quickly becomes clear what Unum’s  playbook really is.

Let me say first and foremost that targeting specific claims for denial at the end of a financial reporting period to bolster profitability at the expense of insureds and claimants is an unfair claims practice. It was unfair when Unum management forced me to do it, and it’s unfair today.

Common indicators of targeting claims include multiple and often harassing attempts to obtain medical paperwork beyond the 15th of the month of profit reporting whether it be the end of a month, quarter or year-end. IME and field visit requests seem to come out of the woodwork as Unum claim specialists are pushed to do whatever is necessary to obtain back-up to deny more claims.

Arbitrary and unreasonable deadlines for submission of additional information are communicated as Unum staff prepares to carry out its “primary plan directions” or ERDs (Expected Recovery Dates) by certain dates corresponding with profitability reporting.

Management often schedules Saturday “focus” days to locate vulnerable claims that can be denied easily while claims handlers are forced to “present” claims at roundtables in order to obtain “activity” ideas intended to gather file documentation in a hurry. There’s the “Rule of Threes” meaning that claims handlers are sent on hunts to obtain buy-in from three sources that claimants can return to work.

Although Unum no longer hangs thermometers on the wall, or plays the lottery to encourage handlers to deny more claims, it is our understanding from former Unum employees that internal protocols to bolster profits hasn’t changed all that much. These same former employees told us that Unum still has target “sheets” handled to them by managers looking for the “biggest bang for the buck.”

When asked, Unum claims handlers are trained to say, “But we don’t do that anymore.” However, if any state regulator were to engage Unum in a conduct market examination and request random selections of claims denied comparing actual dates of denials, it would be my opinion that the results would indicate a significant increase in claim denials nearing specific periods of financial reporting.

Again, I don’t hear really awful and unfair denial case histories from claimants with The Hartford, Aetna, CIGNA, Reliance Standard, Northwestern Mutual, Principal, Mass Mutual, Dearborn, Ohio National, or any other insurer coinciding with end of the month profitability reporting. DCS,Inc., however, has at least a 50% increase in calls from Unum claimants as we near the end of the month. Since Unum calls increase consistently toward the end of any Unum’s profitability reporting period, it doesn’t appear to be coincidence.

Inherent in all this is the realization that Unum Group hasn’t changed its patterns of practices subsequent to the  multi-state settlement, and in fact appears to be worse in its conduct of business. Also clear, is that Unum earns its poor public reputation honestly in that it continues to engage in practices that are hurtful to the majority of its insureds and claimants.

DCS, Inc. does not expect any disability insurer to automatically “approve” all claims submitted to it. However, all insureds and claimants have a right to expect insurers to afford them fair, objective and equitable claim reviews. ERISA folks have the right to expect insurers review their claims as a fiduciary, deciding indeterminable issues in their favor.

Targeting for profitability remains an unfair claims practice resulting in increased denials to bolster financial reporting at the expense of insureds and claimants. While Unum stockholders may realize an additional 5 cents in dividend per share, Unum insureds and claimants are thrown under the bus for the sake of a mere nickel.

SeveProblemral problems have come up recently involving claimants who return to work part-time while receiving STD and expect to continue to receive residual LTD benefits in the future. Employers are not well-informed as to the “Minimum Hours Worked” provisions in group Plans requiring claimants to be working a minimum number of hours in order to be eligible to receive LTD.

Most policies specifically require 20-30 hours of minimum work time in order to be eligible for LTD. Most insurers attempt to interpret LTD group provisions to mean that in the case of a return to work part-time during STD, claimants must return to the required number of hours in order to be eligible for LTD.

I would maintain, however, that dates of disability do not change when claims transition from STD to LTD. Claimants must be working the minimum number of hours just prior to their “date of disability“. Therefore, if a claimant was working 30 hours just prior to his date of disability but returned to part-time work of 20 hours, he still met the minimum hours requirement prior to his date of disability.

These are the types of issues employers can’t explain to you because they don’t know anything about the provisions in their own group Plans.  And…I’m sure benefits have been denied as a result of unknowledgeable claims handlers and managers.

Once again, calls to DCS have indicated that claimants haven’t bothered to obtain copies of their SPD (Summary Plan Descriptions) or Certificate Booklets (Plan or policies) prior to filing for STD or returning to work. I can’t write enough about the importance of obtaining, reading and understanding one’s group Plan before going out on disability.

The “Minimum Hours Worked” provision can be significant consideration prior to filing any ERISA claim.

Crying WomanDisability insurance companies have been abusing their discretionary authority in ERISA policies for nearly 50 years. In no other area is this more evident than the “right” of insurers to offset Social Security Disability Income benefits – a system that allows all Americans to subsidize private corporations’ liabilities to pay claims with public money.

Most insurers “force” all ERISA claimants to apply for SSDI, sign unreasonable Payment Option Forms, immediately repay lump sum award money, and then deny claims. In the end, claimants wind up with no SSDI award money, and no benefits. The system of offsetting other income against disability benefits is broken and Congress isn’t looking to fix it.

Amberley telephoned me this morning, and in a tearful way recounted a case history I’ve heard many, many times over the years. Unum forced her to apply for SSDI benefits that took her three years to receive. After repaying Unum the $18,000 she received from SSA as a retroactive payment, Unum denied her claim.

Amberley was diagnosed with fibromyalgia, IBS, and suspected MS. Unum alleges that since SSA refused to provide Unum with her file the company had no other choice but to decide the claim based on medical information it already had. Deciphered – Unum’s physician wrote up a medical review stating restrictions and limitations are not supported.  

That’s all it takes for Unum to deny claims – a medical write-up by a physician who receives annual percentage bonuses for supporting the Unum agenda.

Unum is actually no worse than any other American disability insurer since they all have basically the same procedures and history for recapturing SSDI then denying claims. The practice of allowing insurers to recapture SSDI money is convoluted in that the definition of SSDI is: “Likelihood of disability for next 12 months, unable to perform any occupation in the national economy for which you have training, education and experience, or a disability resulting in death.”

Despite the official definition of eligibility for SSDI disability insurers “force” all ERISA claimants to apply for the entitlement even when they are aware claimants do not meet SSA’s definition, or they are deliberately planning to deny benefits in the future. Many Unum claims contain navilink “primary plan directions” of potential denials while at the same time claims handlers are forcing claimants to apply for total disability SSDI benefits.

Since Amberley was diagnosed with FMS it is likely Unum knew well in advance the company had plans to eventually deny or limit benefits to 24 months. Still, Unum forced Amberley to apply, took her lump sum SSDI award money, and denied her claim. Amberley, by the way, also has a handicapped child and her husband earns $25,000 a year.

In my mind, either Amberley is totally disabled or she isn’t. The age-old argument insurers make, “We have to enforce contract provisions that are very different from SSA’s definition of disability” is a misstatement since SSA’s definition is the same as most definitions of disability after 24 months.

The truth is, disability insurers are looking to recover the cost of their liability for claims and have the best of both worlds when they are allowed to trip estoppel and collect on both ends of the disability claim spectrum. It isn’t fair, and everyone knows it.

The only solution to the problem of financially harming disabled persons covered by group insurance is for employers to offer contributory, non-integrated Plans to employees. Employees would certainly be willing to contribute minutely to the cost of non-integrated Plans in order to receive full benefits without offsets.

(A “non-integrated” Plan is one in which there are no provisions for offsets from “Other Earnings” including SSDI, Workers’ Comp, and/or Retirement Benefits. A “contributory plan” is one in which both employers and employee share the cost of premium.)

The harm caused by disability insurers in forcing claimants to apply for SSDI is unconscionable, and yet neither Congress, nor the states have any interest in fixing a broken system most likely because it affects primarily the American middle class. If SSDI offsets were a serious issue among the wealthy, it would have been changed by now.

Finally, Amberley told me she asked Unum’s claims handler if she realized what Unum did, to which the claims rep responded, “Unum doesn’t do that” – only one of Unum’s many canned responses.

Well, not surprisingly, Unum Group is only one of many American disability insurers allowed to financially harm those who are the most vulnerable among us.

The “offset” system is broken, and it needs to be fixed. My thoughts go with Amberley and her family today.

 

Carrot and StickCarrots for the month of August go out to Mass Mutual and Guardian for engaging in fair and equitable file reviews and maintaining good professional relationships with outside third parties such as consultants and attorneys. DCS, Inc.’s contact with these insurers has been extremely positive. I hope the trend continues, but for the most part, both Mass Mutual and Guardian appear to “do their jobs” while at the same time respecting the fact insureds and claimants are ill. Although the Guardian continues to aggressively risk manage claims at times, there is no indication of deliberate targeting for profit. Remaining honest in a dishonest industry isn’t easy, but hats off the Mass Mutual and Guardian claim specialists for making the effort.

Another carrot is awarded to Met Life, who in recent times recognized their failed attempts at customer service, and have outsourced business to customer service representatives in India. Admitting what you don’t do well is the first step to improvement and DCS, Inc. supports insurers who attempt to “fix” mistakes. Congrats, Met Life….we hope you continue that trend.

DCS, Inc. also awards a carrot to Northwestern Mutual – a company considered the “king” of private disability insurance. DCS, Inc. appreciates the manner in which NWM conducts its business, works with third-parties, and makes fair decisions. Our hats off to NWM claims specialists who are clearly professionals and who are great to work with.

Unum Group continues to be in first place for a DCS, Inc. stick award for disagreeable claim specialists who seem to be sending out written communications containing threats of claim terminations, strong-armed attempts to obtain signed SSDI Authorizations for files, and general poor claims management. Nasty, and threatening Unum claims specialists are usually the result of increased management pressure and stress to deny more claims. There is absolutely no reason for Unum Group as a company to have letter templates of such a negative nature as to cause insureds and claimants to fear when there is no reason to do so. Unum’s letters are unreasonably threatening, contentious, and negative, no doubt deliberate to cause insureds to cooperate with its demands regardless of what they are. Consistently sending out letters that are obviously negative and adverse is a poor way of doing business and lend to Unum’s already poor public reputation.

Prudential is also given a second place stick award for engaging in claims review practices that are unfair and misrepresented by internal RN medical reviews. The company is second only to Unum Group with its egregious claims practices of misrepresenting policy provisions, relying on RN medical reviews, and unfair claim denials.

Employers should consider very carefully all of their options and engage due diligence when selecting Plan providers of group benefits.

Finally, CIGNA is given a small twig for somewhat attempting to abide by the multi-state settlement agreement, but not informing all employees of the necessity of doing so. It’s unclear whether all CIGNA employees are aware of the new claims process requirements.

 

IndiaAs my readers may be well aware Lindanee’s Blog has often compared Met Life’s customer service to “The Walking Dead” since it was so difficult to have any meaningful contact with claims handlers and managers. In fact, my experience with Met Life’s customer service is contacting corporate relations in order to get a call back from group disability.

Recently, a client complained she was contacted by a woman from Met Life who left a message she couldn’t understand. I returned the call and reached Met Life’s customer service representative in India. When I asked about Met Life’s outsourcing its phone calls so far away the representative responded, “Yes, Met Life participates in a global partnership of business.”

This response is almost word for word what I heard from an anti-virus software rep I contacted several years ago also from India. My experience at that time was a disaster, and after concluding I wasn’t getting anywhere, hung up.

However, I have to admit the “global” Met Life representative I spoke to was very polite, answered all my questions, and resolved the problem I called about. Although providing good customer service wasn’t a strong point for Met Life, outsourcing its customer service might be a good thing after all. One problem may be that English-speaking insureds could have a problem understanding dialects and accents from those abroad. Initially, my client said, “I had trouble understanding what she was saying.”

Although politically I don’t favor sending American jobs to global sources, employing insurance customer service representatives overseas may not be a bad idea if it continues to improve Met Life’s ability to have contact with insureds and claimants. In my opinion, Met Life’s customer service was so poor, anything could have been an improvement.

Nevertheless, my current experience with Met Life’s “global resources” was positive and I’m happy with the communication of information provided to me. We’ll have to keep an open mind moving forward and hope the improvement is long-lasting and a step in the right direction.

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