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Carrot & Stick Awards

Carrot and StickA well deserved carrot is awarded to Mass Mutual for its continuous professional claims management for policyholders who are also owners. The company appears to be managing ERISA group claims in good faith for the time being. DCS has not observed any deliberate targeting of claims, or aggressive risk management deliberately adverse to claimants. We applaud any disability insurer who is able to manage claims in an appropriate manner when the industry as a whole remains corrupt. Thanks, MM!

A hats-off carrot is also given to employers who become involved on behalf of employees when Unum’s internal practices are financially harmful. One employer this week actually extended their internal transitional leave so that its employee would not have to pay back money for benefits or health services received. It is hoped that employers who continuously find themselves in positions of having to defend employees against an unfair third-party administrator or insurer will replace the company at the next annual enrollment period. Employers rarely get involved, but this one did, and saved its employee a great deal of harm caused by Unum.

A definite stick goes to Lincoln Financial who rarely overturns prior denial decisions on appeal. The company also deprives claimants of the benefit of a full 180-day appeal period allowing only one shot to submit additional information in support of claim. Lincoln is a tough cookie to crack these days and the best chance insureds and claimants have is in avoiding denials in the first place. In order to overturn a Lincoln denial one would need to submit a preponderance of objective evidence in support of claim, and even then it would be questionable as to whether the denial would be overturned and claims paid.

Due to Lincoln’s failure to consider payment of claims on appeal it is also in third place for the worst insurer in America. Unum and Prudential are numbers 1 and 2.

Finally, a stick is awarded to The Hartford’s claims handler who sent threatening letters concerning SSDI estimates and reductions from benefits to claimants and won’t return phone calls. In our opinion anyone who works for an insurance company who threatens to reduce benefits unfairly should at least pick up the phone and accept responsibility for his actions.

In this particular case, The Hartford’s claims specialist hit the roof when our client fired The Advocator Group and retained her own SSDI attorney. Apparently, The Advocator Group made quite a few errors in managing her application, and fed up, the claimant terminated the relationship. The Hartford immediately stepped in and assumed the claimant refused to continue her application for SSDI and informed her the next benefit would be reduced by an estimate for SSDI.

The claims handler’s reaction is overkill since what he should have done was find out if the claimant hired an attorney to continue the appeal to an Administrative Law Judge before threatening an offset from benefits. Insurance companies really know how to push claimant’s buttons, particularly when benefits are challenged. Hartford’s claims handler well deserves a stick.

Pop Goes the weasel

This is just a reminder that we are heading toward the end of the 3rd Qtr. profitability reporting period and most insurers are diligently searching for deniable claims to bolster profitability.  Although not all insurers behave in the same ways, most increase “risk management” activities such as  IME, field visit and patient note requests, including attempts for phone interviews.

It’s hard to imagine sometimes how disability insurers can deny claims unfairly to increase their profitability. Just the other day, a caller said to me, “How can they get away with this?” And, of course, that’s the real question isn’t it?

When questioned about claim targeting insurers respond, “We don’t do that” even though, for example, former Unum employees insist the company attempts to bolster profits at month or quarter end. Insurers “get away with it” because they are entitled to fully investigate claims and have (in about half of the states) full discretion to determine who will and won’t get paid. “Discretionary authority” is not entirely a thing of the past, and insurers “get away with” denying claims unfairly just because they can.

Insureds and claimants should make sure that all requested paperwork is verified received by their insurers and continue to request all communications in writing.

Businessman yellingIn 2014, DCS, Inc. turned down several cases when it became obvious all insureds wanted to do was pick fights with their disability insurers. Given today’s ability to research and obtain information on the Internet, it isn’t surprising that insureds and claimants wind up “putting the cuffs on” and refuse to take them off even when it isn’t necessary to go into the ring.

Disability policies are legal contracts between two entities – an insured and an insurer. ERISA folks are “certificate holders” of employee group Plans between employers and Plan Administrators. All parties to a contract have specific duties, responsibilities and accountability written in the contract itself. When both parties abide by provisions set forth in the contract they are said to be in compliance with policy provisions.

Nearly all disability policies require insurers to pay benefits if the “proof of claim” submitted meets the definition of disability as it is defined in the policy. Insurance companies have (in about half of the states) complete discretionary authority to decide what is and what isn’t proof of claim and what the policy means.

Still, insurers are required to pay benefits when, due to medical or mental disability, insureds are unable to work. This may be a bit over simplified, but insurers have contractual responsibilities to pay benefits – disability benefits, COLA, retirement contributions, and other benefit riders contained within policy contracts. On those occasions when insurers pay benefits, they are in compliance with their obligation under the policy.

After spending countless hours on the Internet researching every negative discussion regarding disability insurance, some insureds and claimants actually look for reasons to remain in conflict with their insurers. Here’s a good example.

Mr. S. has been receiving disability benefits from Unum for the last 10 years. Although he continues to work part-time the nature of his business was such that it made sense not to report monthly P&L information to Unum, and at the time Unum accepted yearly tax returns to average and true up benefits actually paid. I spoke to Mr. S. many years ago and refused to take his case because he wanted to find reasons to argue with Unum even when the company appeared to be bending over backwards to accommodate his business and how he reported income.

DCS received an unexpected call from Mr. S. this week once again looking to hire a consultant to assist him with his Unum conflicts. Current issues centered on the fact that Unum is withholding his benefit because it now requests monthly P&Ls in order to compare “apples to apples” and pay him accurately. Mr. S. told me, “I’m going to retain counsel and sue Unum for changing its mind and making me send in monthly financial information. They want tax information too, and I’m not sending it!”

I declined the case again. First of all, Unum has the right to change its mind and request financial information in different formats if it can defend via the policy that it makes reasonable sense and will result in the payment of accurate benefits. Actually, Unum’s request is consistent with its new “crackdown” on forcing all insureds to submit monthly P&Ls. It DOES make sense to request monthly P&Ls since benefits are paid on a monthly basis.

It is also reasonable for any insurance company to request annual tax returns from insureds who are receiving “residual” benefits. This is an argument Mr. S. probably won’t win. Before I let Mr. S. end the conversation I advised him that the shortest distance to conflict resolution in this case is to provide Unum with monthly P&Ls and annual tax returns. If he doesn’t do that, Unum will not pay him until he does.

Unfortunately, I didn’t get a sense from Mr. S. that he intended to take my advice. He wanted a fight with Unum even though the claims handler informed him in writing the company didn’t have a problem paying his claim as long as he submitted monthly P&Ls. Mr. S. is bringing on a conflict that in reality shouldn’t exist.

Most deliberate conflicts with disability insurers stem from the idea, “I have to DO something in order to get paid.” Actually, there are times when the best thing to DO is NOTHING. In fact, insureds and claimants who contact and/or write insurers on a frequent basis create red flags bringing on the lion’s share of investigative “risk activity.” One of my most often used comments to insureds is: “If it isn’t broken, don’t try to fix it.”

Some insureds continuously engage in what I call, “bringing up the who done its.” As one insured told me recently, “Ten years ago, Met Life accused me of not sending in my medical information on time, and then they did this……..and then they did that…..and that one claims handler was terrible….and they overturned the appeal and paid my claim….and then that nasty old claims handler…….”

Although conversations like this can go on for hours, my question was, “Is Met Life paying your claim?” “Well, yes”, the claimant replied, “Met Life has been paying my claim for over 12 years.” At the end of the conversation it was determined there was no real conflict at all, and the insured really didn’t need my help.

While I am the first to admit there are many occasions when insureds should “push back” to defend their disability claims, there is generally no reason why anyone should remain in constant conflict with his/her insurer. The difficult part for insureds is determining which conflicts can be won, and those that can’t.

Finally, insureds and claimants should also consider the emotional stress and anxiety caused by constant conflict. It takes a lot of energy and physical stamina to continuously argue with an insurance company. In fact, over the years I have often said that managing disability claims is equal to having a secondary cause of disability. In many ways, DCS’ patterns of practice include advising claimants to “take a step back” and move forward professionally in an entirely different direction.

Those who read Lindanee’s Blog on a regular basis know that I will defend and advocate for any insured or claimant when there are accurate and reasonably supported issues of bad faith or unfair claims practices. At the same time, my first goal is to opt for conflict resolution so that at some point no further claim conflicts exist, and claimants continue to receive benefits under the terms of their policies and live in peace.

Ranting and continuously picking fights with disability insurers is not an acceptable way of managing disability claims. After a period of time insureds find themselves managing the conflict instead of their claims. It’s a merry-go-round insureds do not need when ill and unable to work.

If there are “issues” to be fought with disability insurers, the goal should always be to resolve conflicts in accordance with your rights under the terms of the policy contract.

Finally, insureds should carefully consider the high cost of conflict health wise and refrain from “picking” unnecessary fights with insurers when they are in fact meeting obligations under the contract policy or Plan.

The best way to manage disability claims is to resolve conflicts rather than constantly looking for ways to argue.  As I said, “If it isn’t broken, don’t try to fix it.”

OuthouseAlthough I am always looking for Unum best practices to write about I am often disappointed when DCS, Inc. receives an overwhelming number of calls from insureds and claimants reporting just the opposite. While one always hopes Unum will recognize the errors of its ways and adopt internal practices of benefit to insureds, the company continues to engage in unfair practices surpassing multi-state settlement levels.

DCS, Inc. received a call from an insured recounting how Unum has taken a year to review his cardiac claim and still hasn’t made a decision. Apparently, after his diagnosis of cardiomyopathy, and heart failure, he filed a claim with Unum back in October 2013. After experiencing further a fib problems requiring him to wear a “life vest”, and having an Ejection Fraction of 35%, Unum is still asking him to submit paperwork such as an “activity questionnaire” before it will make a liability decision.

Of late, Unum’s pattern of practice seems to be to request information by “making it up as you go along” rather than providing insureds and claimants with a list of documentation needed shortly after application so that the required paperwork can be reviewed in a timely fashion. It makes sense to me that if you want to delay the payment of claims as much as possible, a good way to do that would be to continuously request more and more paperwork over time rather than all at once.

However, I’m also of the opinion that Unum’s claims handlers are often not the sharpest knives in the drawer and initiate claims procedures that are way over the top even for Unum. It’s unclear sometimes whether claims specialists are acting on their own, or following company protocols.

In any event, not making decisions on claims for as much as 6 months (much less a year) is completely inappropriate and should be reported to the state departments of insurance. Each state has statues limiting the amount of time insurers have to make liability decisions. ERISA claimants should have claim decisions within 90 days. Waiting and waiting without benefits is not something insureds and claimants should “put up with” and late decisions should immediately be reported to the proper authority.

Another ongoing issue with Unum is that in violation of the multi-state agreements and RSA amendments the company continues to ignore all medical R&Ls and recommendations rendered from outside the company. Again, it is very easy to deny claims when the only opinions considered are is own.

What concerns me is that Unum’s medical review includes a hierarchy of internal physician reviews going up a credential latter for the purpose of creating an illusion that decisions to deny claims are the only decisions that can be made. Unum’s denial letters write, “we referred your claim to our internal ‘board certified physician”, and then “we referred your claim to a second physician who said…”, and finally, we referred your claim “to another board certified physician.”

Since no physician on the Unum ladder disagrees with the ones below, Unum’s efforts to “make the reviews appear credible” begin to appear as overkill to legitimize terminations of claims. Also of concern is that state departments of insurance are drawn into the deception and generally accept the fact that since there was more than one opinion contained in the file decisions to deny claims are accurate. How smart do you have to be these days to identify the deception?

Medical review has always been a sore spot for Unum. With the exception of the period from 2001-2008 when state lead regulators were still watching, Unum’s medical review procedures, in my opinion, were/are deliberately designed to deny claims that should be paid in order to bolster profitability.

This opinion was countered yesterday by a call from a former Unum physician who told me in 2000-2002 he reviewed claims fairly and wasn’t pressured to document anything else. Of course, his tenure with Unum was during the multi-state investigation years when Unum’s management boasted to the press it paid 98% of claims. (If I had been a stockholder at the time I would have run for cover. Paying 98% of claims means the company paid nearly 40% more claims than it probably should have.)

Clearly, ignoring all medical information obtained from treating physicians as well as social security is an unfair claims practice for which I believe Unum will be taken to the cleaners for…..again. Insureds can go to the Maine Department of Insurance website and read the RSA (Regulatory Settlement Amendments) including the requirement to document reasons why treating physicians statements are not given weight. Unum is in violation of this particular amendment on an ongoing basis.

Finally, Unum’s review of “residual” disability claims for professionals who continue working in some capacity borders, in  my opinion, on bad faith. Unum absolutely will not pay residual claims unless P&L information is submitted in a monthly format. This was demonstrated recently when Unum withheld payment of a claim until the insured paid his accountant $6,000 to re-format 3 years of financial information into monthly reports.

To my knowledge no Unum Life, Provident, or Paul Revere policy specifically requires insureds to provide financial information in any particular format. In addition, given the differing methods of conducting business “averaging” often makes more sense than monthly fluctuations from profitability to no income at all. Still, Unum remains steadfast in its efforts to delay payment of claims until insureds “bow, heel, and kneel” to its demands for income reporting formats even if it costs insureds unreasonable accounting fees to produce it.

If one looks at the growing number of Unum complaints and lawsuits overall, it appears the company is worse in its conduct of business than ever. Reports of Unum claim specialists, who are now conducting business in unprofessional ways, may indicate levels of pressure placed upon them by management to deny more and more claims. It has always been my experience in dealing with Unum that “nasty” claims handlers are the result of undue pressure placed on claims personnel to meet profitability targets.

It’s interesting to me as a consultant who reads thousands of Unum correspondences a year that the company is breaking bad again (or still). Other than CIGNA, which had a multi-state investigation agreement of its own in 2013, no other insurance company conducts business the way Unum does. This makes it really miserable for the 500,000 plus insureds and claimants who submit disability claims to Unum each year.

Therefore, while I continue to look for reasons to compliment or write favorably about Unum, calls, correspondence and emails to DCS continue to report Unum as breaking bad in order to bolster profits.

As a former employee I still look for Unum management to become Jim Orr’s lighthouse of “We See Farther” as it was in the past. In the end, however, Unum Group remains the outhouse, not the lighthouse, of disability claims management.

Appeals

Fight or Give UpRecently, insureds and claimants have been contacting me with questions regarding appeals they themselves have submitted and are managing. While some individuals are successful in overturning disability claim decisions most are not. DCS, Inc. has never recommended to anyone that they attempt to manage an appeal on their own, particularly an ERISA appeal.

Most insurance companies explain in their denial letters “that you have the right to appeal within 180 days”, and if you send a letter explaining why the decision was wrong you can request an appeal. Although the information described in most denial letters is true, it isn’t the whole truth. Claimants who do exactly what is described in their denial letters and nothing else probably won’t be successful in overturning denial  decisions.

Filing an appeal is not easy in today’s insurance environment, and it requires a great deal of knowledge and money to obtain what is necessary to convince insurers claims should be paid not denied. I actually work for several attorneys as their consultant and have patterned appeals I assist with after protocols thought by them to provide the best possible case for overturns at the appeals level. Insureds may not need an attorney during the claims process but, if claims aren’t overturned on appeal the only option left is an attorney, if claimants can find one to take their case.

Most attorneys these days will not take non-wealthy claims under $4,000 per month in benefits. This is particularly true of ERISA claimants with  lower monthly benefits. In general, it isn’t worth it to our prestigious “officers of the court” to spend endless hours on ERISA cases when decisions are frequently not make in plaintiff’s’ favor. With respect to managing appeals attorneys are often part of the problem because they leave helpless denied ERISA folks on the train tracks to fight multi-million dollar corporations on their own.

Individuals who call DCS, Inc. for assistance should consider that we cannot immediately jump in after more than half the appeals period has been exhausted. As a company we have our own list of procedures necessary in order to help claimants prepare the best possible set of support documentation possible. ERISA is particular, is time sensitive and Administrative Records should be completely supplemented.

Our recommendation is to either hire a consultant or attorney to assist with appeals from the very beginning. Attempting insurance appeals on your own will land you at an attorneys door eventually if you can find one who actually agrees to review your case. The best defense against insurance appeals is to act proactively while claims are still paid, doing all that is necessary to prevent denials in the first place. No one really wants to end up with a disability claim in court since no one wins except insurers, and of course attorneys.

Friday Q & A

Q&AWill Unum pay a claim when the claimant is receiving fertility treatments?

Although the choice of a couple to receive fertility treatment is a very personal one, most insurers view such treatment as deliberate avoidance of returning to work.

The purpose of fertility treatment is to be able to conceive and have a baby. If a female claimant leaves work, let’s say for chronic back pain, but then continues with fertility treatments and subsequently becomes pregnant, the insurance company may allege that she really wasn’t trying very hard to return to work, but instead decided to have a baby and remain on disability. Unum has even gone so far as to say that caring for a young infant equates to work capacity and the mother could have returned to work. Basically, insurers have no understanding of why any female claimant, already impaired, would want to have a baby, and will render claims decisions accordingly.

Although most of us probably would conclude that decisions to have children are far beyond the scope of disability claims, most insurers would disagree. Insurance companies tend to see caring for small infants as a “great deal of work” and therefore, women who conceive while disabled have work capacity. Likewise, receiving fertility treatments while disabled is also viewed as counter to “getting better to return to work.”

Although I have no opinion on the matter, I am aware that insurers expect claimants to seek treatment to return to work, not engage in treatments to conceive and care for small infants while still receiving benefits. Each case is reviewed by insurers on an individual basis and decisions are made to pay or not pay claims in accordance with what insurers interpret as “work capacity.”

“I think I may have told the claims specialist the wrong thing on the phone. What do I do now?”

To begin, DCS, Inc. has never recommended to anyone that they speak to claims specialists on the phone, nor do we recommend corresponding with any insurer using specially created “secure” websites complete with cookies and snoop software. Still, we receive many calls from those who think, “If I just tell the insurance company everything, my claim will be secure.”

For example, I received a call from a female claimant distraught because her STD claim was denied for “failure to provide medical restrictions and limitations in patient notes.” After, she read the denial letter the claimant called Unum’s rep on the phone and said, “Yes, I agree my patient notes are lacking in information and I’ll contact my physician.”

This kind of verbal communication buys into the insurer’s decision to deny the claim even when the claimant doesn’t really know if the patient notes were really “lacking” or not.

Unum could have used any excuse to not pay her claim. Verbal communication is the major source of information for insurers. Once said, claimants cannot retract or take back information provided to a claims handler.

Moving forward, though, claimants can request all communications take place in writing so that they can have ample time to actually think about how to respond. All insureds and claimants should take all of the necessary measures to create the all important paper trails in case the claims are forwarded later to an attorney for litigation. I cannot stress enough the importance of opting for written communications.

Daily Buzz

Reminders

Claimants Caught In The Crossfire

Claimants still seem to be caught in the “minimum number of hours worked” provision of group Plans requiring them to have worked 20-30 hours just prior to their date of disability in order to be eligible for LTD. New problems with the provision emerge, particularly in the per diem or part-time medical occupations when regular hours worked fluctuates from week to week. In some instances even averaging hours worked for a month does not meet 30 required hours per week despite the fact employees contribute to premium.

In my opinion, unknowing employers are to blame for these debacles. If part-timers are eligible and are included in a “Class” of employee on the SPD (Summary Plan Description), then the minimum number of hours worked should be 20 not 30, giving them amply opportunity to meet the provision. If it is the intent of the employer, however, to NOT cover part-time workers, then say so in the “Class” section of the policy and use 30 hours as the minimum hours worked. How angry would you be to find out that you’ve been paying premium on a LTD policy you would never be able to claim on?

Unum’s End Of Period Targeting

DCS, Inc. received a phone call from a former Unum employee letting us know that Unum claim managers do in fact put pressure on claims handlers to deny claims at the end of a financial reporting period. Apparently, managers still have access to financial reserves and continue to target vulnerable claims for quick denials. I hate to be right……

Former Unum claims specialists may contact me at any time to discuss their terminations. In some cases we can recommend good employment attorneys, or inform concerning Human Rights violations. I’m here and willing to listen.

Also, there is some recent evidence to suggest Unum is once again using IMEs as a major focus to obtain documentation favorable to claim denials. Although all insurers have the right to obtain IME opinions it is a well-known public fact that these evaluations are not “independent, fair” or conducted for the purpose of determining disease and physical ability for work. Most independent medical evaluations result in opinions bought and paid for by the insurance industry. Bottom line? Unum wouldn’t be focusing on obtaining IMEs if they weren’t profitable.

This is a reminder that Unum is the only insurer that has a problem with late checks after holidays. Checks can be as much as a week or two late after Labor Day. This is the ONLY time DCS, Inc. recommends calling claims handlers to ask, “When can I expect to receive my check?” Claimants with policies from other insurers generally do not have to worry about late checks.

State Regulations? Really?

Don’t let claims handlers tell you they are only acting in accordance with “state regulations”, particularly for ERISA claims. ERISA pre-empts state regulations such as requiring insurers to provide status reports every 20 days. It’s more likely internal protocols are the reason why claims handlers do what they do, not state regulations. I’ve never known any insurance claims handler to cite state regulations, (if in fact they ever knew what they were), as administrative cause for acting in a certain way. Insureds may not be aware of the truth and will accept explanations that misrepresent the “intent” to harass or request information over and over again. Verbal conversations with claims handlers make it possible to misstate facts whereas claims handlers would not blame “state regulations” for their actions in writing. This is yet another argument in favor of “in writing only” communications.

Unum Settlements Are All Over The Place

Unum has been offering several different types of settlements lately, but they’ve changed their “commutation” procedures to a “bass ackwards” way of doing things. In the past, Unum investigated and updated all medical, vocational and financial information prior to approaching insureds and claimants about lump-sum settlement. In other words, Unum made sure it would have liability for claims to maximum duration before even suggesting settlement was a possibility. Apparently, all of that has been reversed since Unum is offering settlement amounts, but at the same time informing “it will update all medical information” after the fact. At least in one instance I know of, Unum “took back” its offer of settlement after it  updated medical information and changed its mind.

In my opinion, this is not an ethical way of doing business. What will Unum do if an offer of settlement is quickly accepted and the release paperwork is sent back to Unum before any medical updates can be obtained? Unum’s current procedure has the potential of becoming a legal mess.

In addition, settlements offered to insureds appear to be “low-ball” and occasionally in error. For example, two insureds I am aware of were offered settlements paying for only 5-8 years when their DI policy provisions paid for Lifetime benefits. Why? In once case the “commutation” specialist admitted Unum under-reserved the claim and couldn’t offer lump-sum settlement for greater than the reserved amount. In other cases Unum appears to be offering glorified Advance Pay and Close settlements anticipating future returns to work that don’t exist.

Although I’ve publicly said that Unum’s “settlements” are areas in which I thought the company was basically honest, I’m now of the opinion that might not be accurate. In their haste to rid themselves of certain claims, the company is now engaging in settlement procedures that should cause insureds and claimants to sit up and take notice. There are also a few instances when settlement refusal is met with requests for IMEs and other risk management activity.

Although I realize Unum prefers to change the names of its internal procedures frequently, the word “commutation” is really awful since the word is most often used in the negative context of “commutation of sentence”. In my mind, “settlement specialist is so much more positive; “commutation specialist” sounds like a worker in the prison’s probation department.

 

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