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DCS Sticky Note

Post it noteFor those who may have been wondering, the “Group” identified in the name “Unum Group” refers to the company’s subsidiaries listed below. Those of you who are Unum insureds may recall that all mail is sent to Unum’s communication center in Columbia SC which is the same location as Colonial Life and Accident Company. Paul Revere and the Provident Companies were acquired by Unum Life Insurance Company of America in June 1999, and the company was renamed UnumProvident.

Tim Arnold, the former VP of claims for UnumProvident is now Senior Vice President of Sales and Marketing for Colonial Life and Accident Company. Ann Houser another VP from UnumProvident is President of US Human Resource Operations for Unum and Colonial Life. You can easily see the close connection between Unum Group, and Colonial Life and Accident Insurance Company.

The bad news is, of course, that one claims process permeates through all companies including for insureds who hold products purchased from Colonial Life.  Buying Colonial Life insurance products won’t save you from Unum’s unfair claims practices.

Colonial Life and Accident Insurance Company
The Paul Revere Life Insurance Company
Provident Life and Accident Insurance Company
Provident Life and Casualty Insurance Company
First Unum Life Insurance Company
Unum Life Insurance Company of America
Unum Limited (UK and Europe)

Unum isn’t just one company, but a collection of operating subsidiaries. In the past Unum Life Insurance Company of America also owned Duncanson & Holt, Unum America, Unum Enterprise, and for a brief time Unum Japan. These companies went by the wayside after the 1999 merger, but Unum still owns the seven subsidiaries listed above.

DSM VClearly, disability insurers have bought into the controversy of renaming the DSM-IV “Somatoform Disorder” (300.81) to “Somatic Symptom Disorder” or SSD. Under the old DSM-IV Somatoform Disorder was defined as “a preoccupation with physical symptoms that suggest general medical conditions not fully explained by medical science.” (The word “somatoform” generally refers to imagined or “all in one’s head.)

However, in the new DSM-V SSD is defined as:

  1. Disproportionate thoughts about the seriousness of symptoms lasting at least 6 months;
  2. A high level of anxiety about symptoms and health;
  3. Devoting excessive time and energy to their symptoms or health concerns.

However, under the DSM-V criteria 1 in 6 cancer and CAD patients meet the definition of Somatic Symptom Disorder and has psychiatrists wondering if we really want to burden and stigmatize seriously ill people with an added diagnosis of mental illness.

“That’s OK with us”, claims the insurance industry that has its eyes on unimaginable profits from denying claims after 24 months. The DSM-V simply defines SSD as “excessive preoccupation with thoughts about bodily symptoms and functions in combination with high levels of anxiety about health.” Who doesn’t worry about their health these days?  Are we all mentally ill?

The new criteria of the DSM-V comes after nearly a decade of cultural, governmental, media and social awareness of “better health for America.” Populations today are much better informed about “living healthier and longer”; perhaps more attention is paid today on “wellness” than at any time in our history.  Worry and concern about “eating right” and “getting up on that treadmill” has become an American obsession but has not ever been defined as a “mental disorder.”

Will there ever be a “normal concern” over one’s health allowed without being classified as “somatic” or “it’s all in  your head?” As with many other things, once the line is crossed with hypocrisy, it’s hard to take it back.

Impairments redefined by the DSM-V as Somatic Symptom Disease include CFS, FMS, IBS, chronic Lyme disease (late stage), Interstitial Cystitis, Gulf War Syndrome or PTSD, and Chemical Sensitivity. These medical illnesses will become misdiagnosed as mental disorders because of the criteria listed in the DSM-V.

In other words, if you have cancer, diabetes, heart disease or kidney failure and your worries and concerns about your illness are (in a psychiatrist’s opinion) chronic and excessive, then you will be diagnosed with a mental illness. For private disability, the DSM-V opens the door to even more abuse of the Mental and Nervous 24-month limitation in LTD policies.

After all, according to the insurance industry, it is a widely accepted fact that some people do indeed worry to a considerable degree about illnesses they believe they have, even though repeated examinations by physicians produce no evidence of illness. Individuals are in effect worrying about non-existent conditions. For nearly 10 years the American Psychological Association has label these people as mentally ill, why not redefine “imaginary illness” for what it is?

Redefine indeed since the DSM-V goes so far as to include parents and other family members into its diagnostic criteria. Parents with terminally ill children who obsessively worry about losing their children can now be classified as mentally ill.

As a 20-year veteran consultant it is my opinion that recent changes in the DSM-V should come as no great surprise. Disability insurance lobbyists and renowned research physicians in America and the UK have long been searching for ways to eliminate CFS and FMS from permanent causes of disability. Unable to convince the CDC to officially defined CFS as a mental disorder, changes in the DSM-V are more underhanded and less visible to those who apply for disability insurance.

It is also clear disability insurers can now classify nearly any diagnosis as mental illness if patient notes and other medical records show evidences of “excessive thought” or worry about symptoms that cannot be proven to exist by medical examination or science.” The implication here is that if upon examination, physician’s can’t find anything wrong with you, you’re not sick; if you keep worrying about it, you’re mentally ill.

The ultimate consequences to those who file private disability claims could be astounding because of the increased numbers of disability claims that potentially could be denied, or limited to 24-months of paid benefits. The logic contained within the new Somatic Symptom Disorder diagnostic criteria is missing. How does a heart transplant or cancer insured NOT excessively worry about his/her health?

Clearly, disability insurers will have a financial vested interest in taking advantage of the DSM-V and its redefinition of what constitutes a “somatic disorder.”

ShreddingReliable sources informed DCS this week there is a distinct possibility that The Standard is sanitizing claim files and shredding claim file information prior to releasing copies of files outside the company. Sources currently in litigation against The Standard told DCS that “they had evidences of shredding going on at the company.” This is a very serious breach of ERISA disclosure statutes as well as deceptive claims practices intended to shield not only The Standard’s internal claims process but prevent attorneys in litigation from using file documents against the company.

A copy of The Standard’s Claims Manual used to train employee’s “reads like an SS guidebook” sources said.  While The Standard has never been recognized as either a good or bad insurance company, evidences of shredding isn’t a good thing.

In 2004 Unum was also accused of sanitizing claim documents and shredding memos and other reports after the NBC Dateline and 60 Minutes TV exposes. Although I can’t honestly say I witnessed the shredding of actual documents, I was told by my administrative assistant that he saw managers shredding documents. This one piece of information told to me by someone I trusted caused me a great deal of grief when I protected him from identification during a deposition. Many attorneys after my testimony felt compelled to pooh-pooh later statements I gave because I wouldn’t give him up.

Tom Benvie, an elderly administrative assistant died not too long ago, but he did communicate to me evidences of managerial shredding at that time. On the other hand, “sanitizing” claim files was a common occurrence at Unum and was actually part of my training as a Unum Disability Benefit Specialist. At the time, I was taught by Unum to remove certain documents such as internal blue memos, primary direction descriptions, internal reviews, and any other derogatory information contained within claim files even when subpoenas were received.

UnumProvident took quite a slap from regulators for sanitizing claim files which is why I’m surprised other insurers like The Standard continue the practice. Perhaps the company was/is arrogant enough to think it would never get caught. Whatever the reason, shredding key documents and sanitizing files (removing documents) is bad faith, if not illegal. If claim files are reviewed by The Standard in good faith in a fair and equitable manner why is the company shredding documents? Good question.

Internally, disability insurers often conduct reviews wherein discussions and documentation of those discussions takes place. In order to move files through the process and allow subsequent reviewers the benefit of prior reviews and team meetings, documentation is maintained whether the claim file is in paper or electronic format. My suspicion is that surveillance documentation might be over the line of legality at times and is removed from files as well.

Untrained claims handlers can also document claim files with inappropriate comments such as “this claimant is crazy”, or “claimant is weird, I’m going to deny the claim.” There used to be a saying at Unum, “If it isn’t in the claim file, it didn’t happen.” If negative information wound up in the claim file by mistake, UnumProvident’s claims handlers could take care of that soon enough by removing and destroying the information.

This new tip about The Standard should remind all of us that insurers may not have learned from Unum’s mistakes and continue to engage in claims practices that harm insureds by preventing full disclosure of internal reviews and standards.

If the information communicated to DCS is accurate, The Standard may not be the only insurer removing documents and shredding them.

Angry at InsurerApparently, there are insureds and claimants who are so angry with their disability insurers that they are choosing to fight over issues resulting in claim denials. Since it is very easy anyway for insurers to terminate claims without cause, it is devastating to DCS to learn insureds are throwing themselves under the proverbial bus for conflicts they will never win.

It might be a good idea to clear up the issue of whether or not insureds are required to provide personal and business tax returns. From some of the newer policies I’ve audited, many insurers have closed the loophole and now include contractual language requiring claimants to provide them.  Absent such language, it has always made sense for ERISA Plan holders to provide tax returns IF they are working part-time and are paid residually under the policy. Insurers do have a reasonable expectation to require tax returns to “true-up” part-time wages and benefits paid.

Claimants and insureds who work part-time, have equity ownership interests in other businesses and those who keep corporations active in their domicile states, should always keep copies of tax returns to provide to disability insurers when asked for them. The “reasonable test” applies here and of all the reasons why disability claims are denied, refusing to provide insurers with tax returns shouldn’t be one of them.  Read your policies carefully to determine what is considered income. If you fall into that category in any way, expect your insurer to request tax returns.

In the past, most insurers have given claimants some lead-way in providing other information such as occupational questionnaires, APS and Progress Statements etc., but it looks as though most have now changed their positions and are holding claimants accountable for timelines. By far the majority of group LTD Plans allow claimants 30-45 days to provide information once it’s requested. After that, insurers have the right to deny claims if the information isn’t received. DI policyholders have 90 days after the end of a claimed disability period to submit proof of claim. Pushing those timelines because of anger could result in terminated benefits.

Insureds and claimants I speak with have researched so much information on the Internet about disability claims they express a great deal of anger toward insurers who withhold or won’t pay benefits. I hear a lot about, “Well, that’s bad faith”, and “the whole system is corrupt”, and ” I’m going to make them pay everything they owe me!” The truth is, although the disability insurance industry IS corrupt and the insurance IS a poor risk, required federal and state regulations needed to be adopted to improve the system are much larger issues than just one disability claim.

Refusing to provide requested information creates “red flags” and opens doors to aggressive risk management such as frequent surveillance, IMEs and patient records requests. Once your policy is examined and you’ve applied the “reasonable test”, information should be provided to insurers when requested. Attempts to fight the entire insurance industry on issues not even experienced attorneys are taking on these days is indeed throwing yourself and your claim under the bus.

Besides, disability contracts require both parties to “do some things.” It’s really not a good idea for insureds and claimants to presume they can inflict some sort of penalty or harm on insurers because the industry is corrupt.

With respect to reading information on the Internet (and I include this Blog in the mix), keep in mind that “one size does not fit all.” Just because one person in a disability chat room was denied unfairly does not mean you will be too. Lindanee’s Blog contains posts with “information”, trends, and is not intended to be used  a gospel guide to anyone’s particular claim. Each claim has its own unique set of circumstances.

Insureds should review their policies carefully to determine what is proof of claim and then apply the “reasonable test.” Is it reasonable for Unum, for example, to ask me for my tax return when I’m working part-time? If the request passes the reasonable test, provide the requested information and move on. For goodness sake…..what good is it going to do to withhold a tax return when the claim will be denied?

There are some circumstances when requests for tax returns are NOT reasonable, but you will know and recognize these situations when you come to them. Finally, don’t try to police the entire insurance industry by making insurers “pay” for what they do. These are much bigger issues than just one disability claim and you can never inflict enough harm to insurers to cause them to change their claims practices.

Being angry at your insurer is one thing…….throwing your claim under the bus for conflicts you can’t possibly win is something else.

TruthOne of the reasons I do what I do as a consultant is that disability insurers (and those who work for them) do not tell the truth. There are inherent built-in procedures whereby insurance companies applaud themselves on their ability to put forth only what is favorable unto themselves and the profit motive rather than investigating claims in a fair and objective manner. When the objective is to pay as few claims as possible, it isn’t a long leap from honest communication to pure fabrication. After all, how many times have you received letters from your insurers and have assumed the communications are accurate?

Some disability insurers are better than others at distorting the truth and after twenty years in the claims management business it’s obvious to me Unum Group is at the top of the list of companies who have become experts at deception and misrepresentation. One of the best examples is Unum’s field representative request letters wherein the wording suggests the meeting is mandatory and not voluntary in some cases.

Unum’s letters allege the company wants to “meet you personally and give you an opportunity to ask questions.” Letters present the request by saying “you will be contacted by our field representative to arrange for a meeting”, leading claimants to believe they don’t have a choice. About half of Unum’s policies actually contain provisions requiring claimants to meet with field representatives. Still, claims handlers do not appear to check policies and demand meetings anyway.

Would it be so terrible if Unum’s letters to those without a contractual duty to meet with a field representative said, “Although your policy does not require you to meet with our field representative, we are requesting that you do so anyway so that we may have the opportunity to obtain additional information needed to review your claim?” Unum will never do this obviously because claimants and insureds just like you perhaps haven’t read their policies and blindly agree to anything Unum asks you to do.

I can’t tell you how many times I’ve read Unum’s throw-back in denial letters….”During a field visit you said…….you told our field representative that you…..” Still, in reading Unum’s letters requiring field visits, one might believe what is written is truthful and honest when it isn’t.

Unum’s second great lie involves attempts to obtain SSDI files leading claimants to believe that if they don’t give permission claims won’t be paid, or “we can’t give your claim every consideration.” This is about as untruthful as it gets since Unum’s real motives to obtain SSDI files is to use them in an adversarial manner. Insurance companies should not be permitted to force claimants to sign authorizations for SSDI files when it is known in advance the files will be used in conflict of interest to deny more claims. This is also true of Unum’s new POF form which grants the company voluntary liens to bank assets and personal property if overpayments are not paid back.

Companies such as CIGNA, Aetna and Met Life appear to distort policy provisions, but I find in most instances misrepresentations are mostly due to untrained and unskilled claims specialists who do not know any different. Prudential’s motives are deliberately targeted toward claimants in a more, “it’s our way or the highway” whether it’s legal or not. “So sue us”, Prudential’s claims handlers have been known to say since Prudential doesn’t care what reactions claimants have to their lack of fiduciary duty.

How many times have you hung up the phone and said to yourself, “That’s not what I said”, or “My doctor never said that?” “Where are they getting that information from?” “I was never diagnosed with depression, what’s going on?” Insureds and claimants wind up shaking their heads because of one misrepresentation after another.

Those receiving disability benefits need to know insurers distort, and cover their own “basses” the majority of the time. It’s actually up to insureds to make sure accurate and truthful information is added to the file so that companies like Unum and Prudential won’t have a consensus about anything.

CIGNA, Aetna and MetLife make too many mistakes to let them go uncorrected. Insureds are not dealing with a reputable industry when they file disability claims, and it’s a constant battle ciphering what is true and what’s a lie, or a distortion or misrepresentation of medical records and patient files.

The real truth is the insurance industry isn’t truthful. Those with disability claims  are likely to continue to face challenges in understanding what’s true and what isn’t. Disability insurers are not above deception and that’s a true statement.

IME PhysiciansPerforming insurance Independent Medical Evaluations is a multi-million dollar a year enterprise. Physicians looking to make more money than patient care could ever bring in choose to put medical ethics at the door and support insurance companies planning to “roll in” more and more profits each year. Since IMEs are utilized by private disability insurance, worker’s compensation and social security second-rate physicians looking for big money makers need not search too far. When internal “board certified” internal insurance physicians are added to the mix, disability claims processes are little more than “set-ups” to unsuspecting insureds and claimants looking for a fair shake.

In today’s world, IME physicians can be either overly qualified in areas unsuited to claimed disabilities, or foreign doctors with questionable credentials barely able to speak English. A good case in point is the IME notification from The Hartford DCS received with Dr. Asish Ghoshal, a neurologist who graduated from “All India Institute of Medical Science, New Delhi, India. Information and feedback given at http://www.ratemds.com describes Dr. Ghoshal  as, “Not only rude, but …along with the dirty office, horrible receptionist and not being able to understand the doctor…I waited one and a half hours beyond my appointment time…I guess I should have done my homework.”

Another Dr. Ghoshal patient described services as, “The receptionist, who I believe is his wife, was vulgar and rude. I called and asked for copies of my bills and after being hung up on was later told to send a self-addressed envelope and she would charge me $35 to get the copies. Are you kidding me?” Other feedback included comments such as, “Very unclean office…very poor service, was told to go to ER because they don’t handle complex cases such as seizures…this guy doesn’t know what he’s talking about and isn’t worth the money….his assistant is a real b@#$h and need to have a cigarette break. I would never advise anyone to go there.”

As a consultant I can’t believe The Hartford would hire Dr. Ghoshal to perform IMEs since with this kind of public feedback means he has no credibility. It does bring up a good point, though, that insurers tend to be hiring foreign physicians as way to make IMEs more cost-effective. I seem to be hearing a lot about IME physicians being “flown in”, or using temporary office space to conduct IMEs. Reports from insureds report dirty and cluttered offices, offices in questionable parts of towns, physicians who can’t speak English very well,  and physicians who are rude, rough in examination, or deliberately critical.

In contrast another DCS client reported a very well qualified neuropsychologist in Virginia conducting tests on tables with testing instruments so dirty, he asked that they be cleaned before touching them. Still another reported the IME physician wore a soiled lab coat and the paper on the examining table was soiled as well. All insureds and claimants have a right to a clean examination room with a physician who at least appears “scrubbed” as well.

I don’t think it’s unreasonable to say that most IME physicians are “in it for the money.” And, of course their reports reflect opinions favoring insurers who write the checks. That is not to say that there aren’t honest IME physicians, but indeed they are clearly in the minority.

Sometime ago Unum provided transportation to and from an IME in New York, but the driver left and didn’t come back to pick up the claimant after dark. Scary. Another “provided” Unum transportation was a dirty yellow cab in Philadelphia with a cabbie who got lost and didn’t have gas money. Tales of IME mishaps are a dime a dozen, everyone makes money except the insured or claimant.

Claimants and insureds have the right to be treated well during IME evaluations. Please see below.

INDEPENDENT MEDICAL EVALUATION BILL OF RIGHTS

  • Insureds have the right to schedule the requested IME at a date and time convenient and reasonable for them.
  • Insureds have the right to recover all mileage and food expenses when traveling to and from the IME location; or, have suitable transportation provided to them.
  • Insureds have the right to attend the medical examination with a witness, or audio record the session.
  • Insureds have the right to obtain a Curriculum Vitae from any IME physician.
  • Insureds have the right to bring additional proof of claim to the IME session.
  • Insureds have the right to be examined in an office that is clean, dust free, sanitized, and suitable for medical evaluation.
  • Insureds have the right to be evaluated in a medical office or facility that is in a safe and professional location of town within 40 miles of their residence, or in the same county of residence.
  • Insureds have the right to be examined by a physician with the same board certification or qualification as the insured’s treating physician, or a physician who is qualified by board certification to evaluate insured’s claimed disability.
  • Insured’s physicians have the right to have input into the selected battery of tests when neuropsychological IMEs are requested; treating neuropsychologists have the right to approve the selected battery of tests which are consistent with diagnosing a claimed disability prior to the administration of the evaluation.
  • Insureds have the right to ask questions and to have those questions answered by the IME physician.
  • Insureds have the right to be treated and examined with respect.
  • Insureds have the right to request an ambulance should an injury occur during the IME caused by the IME physician. All medical bills related to such an injury should be billed directly to the insurance company.
  • Insureds have the right to be examined by a physician who speaks and understands English.
  • Insureds have the right to refuse contact with any physician who is not clean and presentable, smells, has not washed his hands, or proceeds with the examination in a rough, painful or unexpected way.
  • Insureds have the right to expect the IME physician to have read their file prior to the IME examination.

Insureds should never allow themselves to be treated in an in humane or disrespectful way. All IME sessions should be journalized in narrative form and forwarded to the insurance company for inclusion in the file. Insurers may have the right to require IMEs, but they do not have the right to subject you to any evaluation which is not professional, clean, and in a proper permanent facility.

Faking itInsurance companies are programmed to assume most insureds filing for disability are either faking or exaggerating their inability to sustain work. It is presumed between 15-20 percent of disability applications received are fraudulent and shouldn’t be paid, therefore, the majority of insureds and claimants endure aggressive risk management so that insurers can locate the minority of claims that are submitted fraudulently. But, it’s more than that.

Disability policies contain provisional language limiting benefits to 24 months at the discretion of insurers. This means all disability insurers can deny claims based on internal medical reviews stating claims are “mental and nervous”; the impairment is “somaticized (all in your head); or due to “self-reported” symptoms. All it takes is an insurance internal review stating primary diagnoses are listed in the DSM-IV (or V), or “self-reported.”

Mental and Nervous disorders as defined for disability claims purposes are mental impairments listed in the DSM-IV(V), Diagnostic and Statistical Manual of Mental Disorders. It is my understanding that although CFS and FMS were not listed specifically as mental disorders in the DSM-IV, they are now listed in the DSM-V as “somaticized” mental disorders. This is why insurers are now denying FMS and CFS under the 24-month mental and nervous provisions of the policy.

The word “somatic” means made-up, exaggerated, or “all in your head.” “Conversion disorder” is a good example of a somaticized disorder that can cause epileptic-like seizures, fainting spells, and even paralysis without any direct physical cause. In general, any disorder listed in the DSM-IV except Alzheimer’s  and organic brain disease is accepted as qualifying for limited benefits in most STD/LTD policies. LTD policies now refer directly to the DSM-IV as reference to impairments for which limited benefits are paid.

Alleging various impairments are “self-reported” is the area in which most claim abuse occurs. By definition, self-reported impairments are those that cannot be backed up by objective evidence confirming what patients and physicians diagnose is actually true. For example, headaches, pain, depression, and Lyme disease are most often characterized as self-reported.

A “severe headache” for one person may not be for someone else.What is painful to one person might not be painful at all to another. Therefore, while most disability polices DO NOT contain wording requiring the “objective evidence standard”, self-reported provisions require objective evidence through the back door so to speak. (If there is no objective evidence, then it must be self-reported.)

Insurance companies also have the view insureds and claimants can “make-up” or fake bad headaches so they can go out on disability, and exaggerate pain to higher levels for the same reason, or to solicit higher doses of pain medication. Some people are able to continue working with rather high levels of pain, others cannot. As a former claims specialist I can tell you there ARE claimants who DO exaggerate symptoms in order to go out on disability or remain on disability longer.

While most insureds and claimants are honest, there are always those who use the opportunity of disability to stay disabled as long as they possibly can instead of going back to work. Those who are legitimately disabled pay a huge price because of those who abuse the system. It actually takes a very serious impairment to last to age 65 or qualify for SSDI.

Mental and nervous provisions limit insurers’ liability for claims beyond 24 months because of the subjective nature of attempting to verify impairments for which there is no objective proof of existence. Insurers are paranoid about obtaining actual psychotherapy notes in an effort to objectify mental illness, but once obtained information is “snatched’ at the expense of the insured to further limit benefits to even shorter payment periods.

Bottom line? Disability policies pay for mental illness and self-reported claims for limited periods of time. Policies are not intended to pay beyond 24 months for mental and nervous disorders. Although most Individual Disability Income policies (non-ERISA) omit mental and nervous limitations, self-reported disabilities are aggressively risk managed with psychological IMEs, neuropsychological evaluations and patient records requests.

Most insurers presume depression claims with appropriate therapy and medication management should be resolved within 12 months. More serious mental impairments such as Bipolar I&II and Personality disorders are paid for longer periods of time although they, too, are aggressively risk managed.

Those who are legitimately disabled due to mental and nervous conditions should apply immediately for SSDI so that when disability benefits end after 24 months, there is additional income available to support financial needs. It’s not a wise idea to depend on disability insurers to pay claims long-term for mental and nervous or self-reported disabilities. There’s just too much abuse built into the process.

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