Friday Q & A

Q&ADoes Unum cover depression after the birth of my baby?

When I am asked questions like this I feel the need to clarify disability policies in general. Private disability is not solely “impairment directed”, but a determination that one’s medical condition prevents him/her from returning to work.

The presumption by claimants and, on occasion their physicians, that private disability is only medically based is entirely wrong. There are two criteria that must be met in the definition of disability: 1) that a medical impairment exists severe enough to warrant restrictions and limitations, and 2) that the restrictions and limitations are severe enough to prevent one from working. Unless insureds and claimants “connect the dots” between medical condition and inability to work, there is no disability claim.

Therefore, to answer the question specifically is, yes, Unum could cover depression after the birth of a baby if the condition is severe enough to prevent returning to work after the normal 6 weeks of maternity leave.

The above discussion applies to ALL impairments. I keep seeing questions such as, “Does Unum cover irritable bowel syndrome?”, or, “Does MetLife cover fibromyalgia? etc.  And again, the answer is that insurers cover any impairment with medical restrictions and limitations that prevents one from working. Both criteria must be met in order to meet the definition of disability in all private and group policies.

Claimants should also keep in mind that a diagnosis does NOT equal disability. Just because your physician has diagnosed you with a medical condition requiring treatment does not necessarily mean you can’t continue working. Many employees continue working with various medical conditions until there are unable to work at the standard required by their employers. Private disability is always determined when medical restrictions and limitations diagnosed by a qualified physician prevent you from working. (Remembering, of course, that insurers themselves determine who meets the definition of disability in the policy and who doesn’t.)

What do I do if I am abused by my employer as a disabled employee?

Employment abuse should be immediately reported to your state Human Rights Commission and EEOC. Then, retain a good employment attorney to discuss any future actions you may have against your employer.

Why do I keep getting paperwork and letters from Unum even if they don’t really say anything new?

Unum’s management wants to know that your claim isn’t part of the claims handler’s backlog. In addition, management requires your claim to be “touched” (reviewed) frequently so that there are no opportunities lost to deny the claim. It’s very interesting, MetLife, Aetna, and CIGNA do not send out enough status letters while Unum sends them out even when they don’t need to. These patterns of practice indicate to me Unum may still be micromanaging the claims process and forcing its claims personnel to set frequent flups. Go figure.

I’m devastated. My company says I can’t get benefits because my claim is pre-existing. What do I do now?

With the exception of catastrophic and sudden disability, pre-existing condition denials should never happen. New employees who are eligible, and are then covered under the employer’s Group STD/LTD Plan should obtain copies of the Certificate Booklet and read it. In the Plan, it will describe under what conditions a claim would be considered pre-existing. Although there are many versions of pre-existing condition provisions, the most common is the 3/12 provision.

The 3/12 pre-existing condition provision states that claims filed within 12 months of the Effective Date of Coverage (EDOC), will have a three-month look-back to determine if the claimant took prescribed medications, or was treated for the same claimed medical condition(s). Claimants treated for the same medical condition during the 3 month look-back are not eligible for benefits.

For example:

Claimants date of hire:  August 1, 2014

Effective Date of LTD Plan:  October 1, 2014

Date of Disability:  December 1, 2014.

Claimant’s date of disability is within 12 months of the Effective Date of Coverage, therefore, the three-month look-back period is May, June and July 2014, If the insured was treated for the  claimed disability, and/or took prescribed medications for the same disability, the claim is determined to be pre-existing and will not be paid.

In order to be eligible for benefits under the employer’s Plan claimants must remain at work at least 12 months from the Effective Date of Coverage. Knowing this in advance, claimants could remain at work as long as possible in order to receive benefits under the Plan. Pre-existing condition denials are very difficult to contest since claimants are either treated during the look-back period or they are not. Unlike other claims decisions, pre-existing conditions are not a matter of opinion, but a matter of mathematics in calculating the look-back period.

A true case in point: A single mother of three was newly hired in August 2014 and immediately became effective (covered) under her employer’s group Plans. Due to severe depression and anxiety her doctor recommended she go out on disability in October.  Ms. S. has a prior history of depression and anxiety and will not be paid benefits under her employer’s LTD Plan because she was treated and took medications during the three-month look-back.

Her options are: 1) return to work with her employer and wait until after August 2015 to file a claim assuming she is still having difficulty; 2) Ms. S. is not eligible for FMLA because she has not worked for her employer for 12 months or 1,250 hours; therefore her employer can terminate employment if she does not return to work; 3) After employment termination, Ms. S. can file for unemployment, but may not receive it if the employer challenges the claim; 4) File for SSDI and wait to see if SSA approves her claim.

I think we can all admit that Ms. S. is in a terrible situation with limited options. Pre-existing condition situations can also become complicated when there are “continuity of coverage” provisions in the group Plans.

Nevertheless, many pre-existing condition denials need not happen if claimants obtained copies of their Plan and knew in advance what to expect.

Daily Buzz

RemindersRMS – The Old Unum

Although Disability RMS boasts of being experts in providing claims management services, the company is quickly becoming a stone in everyone’s shoe. Many of the employees of RMS are “old” Unum employees with same bad habits as Unum Group has. If you visit  the RMS website and read the company’s “core values” it sounds a bit as though all employees definitely have keys to their lockers at the local country club. In fact, in my opinion the website isn’t written very well at all.

One DCS caller described rudeness and bullying on the part of RMS’ claims specialist making her fearful to communicate with the company at all. Another unfortunate claimant is harassed by RMS to apply for both SSDI and the Canadian Pension Plan (CPP). Believe it or not, there are individuals who work across the Canadian border, but live in the US making them eligible for both plans. This could also be true for Railroad Retirement.

In the past, DRMS was unheard of and never mentioned as a bad faith insurer. Recently, however, callers are contacting DCS, Inc. with tales of unfair practices and bullying. It’s time to keep watch and document carefully to see where DRMS is going to go as a risk management company. It can either go the Unum route as an unfair reviewer, or it can remain in the background with satisfied customers.

Sometimes when employees are absorbed from another company it’s hard to clear their heads with new and improved protocols. In any event, we’re watching RMS and hope the company provides the services its boasts of on its website. According to its website RMS currently has 40,000 claims and 350 employees.

The Countdown to Year-End

October begins 4th Qtr. countdown to year-end profitability. Disability insurers will begin to have focus days, roundtables, claim reviews and SSDI audits at accelerated levels in order to find vulnerable claims to deny. This is the time of year when claims specialists would prefer to quit and come back in January because of the stress placed on them to process claims at faster rates. More field visits and IMEs are requested at the end of the year than at any other time.

This means that claims are “targeted” as non-compensable and are “worked” according to a pre-determined, written plan direction to deny prior to December 31, 2014. While most insurance companies pooh-pooh the idea of “targeting claims” by alleging “we don’t do that”, or in Unum’s case, “we don’t do that anymore”, the proof would be to audit claims denied in 4th Qtr. to determine a percentage of the increase in denials over the previous quarters. In fact, such hypothetical audits would most likely show an increase in claim denials in the third month of each quarter – March, June, September and December.

Insureds and claimants should be aware of the potential of extra attention to their claim  in the 4th Qtr. and ensure compliance with requests for additional information, meetings and evaluations.

Webinars in the Future for DCS

DCS’ philosophy has remained dedicated to educating the general public by providing accurate information to insureds and claimants equal to that of insurance companies evaluating claims. In recognition of the fact that claimants cannot defend what they don’t know, DCS continues to provide information about the claims process through Lindanee’s Blog as well as written electronic articles designed exclusively for clients. In keeping with DCS’ education objectives, I will be publishing Webinars with Powerpoint slides on various topics. Although you will not actually see  me, I will be teaching the course, and providing additional information and explanation on various topics.

The production of Webinars is also consistent with NCDI’s objectives and decisions haven’t yet been made to offer the Webinars for a small fee, or for donations. DCS clients will have access to the Webinars for free.

The first Webinar in design is “Understanding  the Definition of Disability in Group ERISA Plans.” Although as a former college educator Powerpoint slides are an old hat to me, the new technology of audio recording isn’t. Therefore, I will let the public know when the first Webinar is ready to be viewed and where it will be available.

For over a decade DCS has been proud to recognize the value of knowledge and education as part of the disability claims process. Stay tuned.

Review the situationMost language in group ERISA Plans state that claimants are required to apply for SSDI “when we determine you are eligible.” Assuming most insurers do not abuse their discretion by forcing claimants to apply when it’s evident they can return to work in some fashion, most claimants will apply for SSDI to avoid estimated offsets even when they know they will be returning to work.

Forcing claimants to apply for SSDI when they have some work capacity actually shoots insurers in the foot since claimants are much less likely to go back to work once SSDI benefits have been awarded. Still, insurers chase the dollar offsets costing the American public millions  in federal funds reviewing SSDI claims for those who do not meet the definition according to SSA’s listings.

During the own occupation period (first 24 months), it isn’t difficult medically to support inability to work at all. The problem is after the change in definition when claimants assume a higher burden of proof of total disability. For most insurers total disability equates to less than sedentary capacity for work and it’s at this time most disability insurers will require claimants to apply for SSDI.

However, not all claimants want to apply for SSDI at the change of definition. Usually, claimants explain to me after 24  months of paid benefits that they are still hoping they can return to work and probably have part or full-time sedentary capacity for work. The conundrum is that it is very difficult to explain to an insurance company that you don’t want to apply for SSDI (because  you’re not totally disabled) while at the same time expecting to get paid benefits beyond 24 months because you are “unable to perform ANY occupation for which you have training, education and experience.”

Either claimants are totally disabled, or they are not; and claimants can’t have it both ways. Employer disability Plans expect that either claimants apply for SSDI after 24 months, or they go back to work in some capacity. My experience is that most claimants will apply for SSDI in the “own occupation” period when insurers threaten to reduce benefits with an offset if they don’t apply. Those who refuse to apply for SSDI for any number of reasons may have a very difficult time explaining how they meet the change of definition written in their group Plans after 24 months.

Another problem is that there are claimants who are not aware of any “change in definition” in their Plans and have absolutely no idea what I’m talking about in this post. If this is the case, I strongly recommend obtaining copies of the Plan and reading the definition of disability.

Some years ago, I was an expert in a qui tam case, Loughren vs. UnumProvident where it was alleged Unum forced all claimants to file for SSDI indiscriminately costing the American public millions in conducting reviews for those who did not meet SSA’s criteria. If you consider the mathematical probability that SSA approved large numbers of claims, even for those with some work capacity, the cost was astronomical. Multiply that same probability by the number of disability insurers in the United States, and the cost initiated by the private disability industry to the American government becomes insane.

For claimants, the realization they have to either go back to work or file for SSDI comes as a surprise. “I’m only 41 years old!”, a claimant tells me on the phone, “anything can happen before I am eligible for SSDI.” Regardless of how true that may be, as a claimant with a private disability Plan, after 24 months it’s either go back to work, or file for SSDI because you are “unable to perform any occupation for which you have training, education and experience.”

Insurers are well aware of the conundrum and push the buttons for everyone to apply for SSDI to ensure maximum profitability to meet their own financial goals.

Unfortunately for claimants, it’s a “put up or shut up” deal since decisions need to be made to either go back to work or prove total SSA disability after the change in definition.

The Green MileSo many middle class Americans find themselves in financial crisis during times of unexpected disability. It isn’t hard to imagine how this can happen when most families in the United States live from one paycheck to the next.

Today, the truth is that unless employers contribute to defined contribution or defined benefit programs, most middle class Americans will not be able to afford to retire much less prepare financially for an unexpected disability. This situation remains a Catch-22 situation in our society since those who can’t take care of themselves eventually become the responsibility of overburdened state welfare programs.

Like the story of the young couple who contacted me this week with a tale of desperation waiting for Unum’s LTD rep to approve and pay benefits. “If we don’t get paid by the end of October, we’ll have to put our house up for sale and move. We went through a lot to get this house and now it’s all going to go down the drain.” Although in retrospect relying on any American disability insurer to pay claims is a mistake, the blow is just as hard to a young family when it becomes clear disability insurance isn’t reliable and may not be there when you need it.

Except for catastrophic circumstances, disability always comes as a fireball in the night. Most insureds tell me, “I never dreamed I wouldn’t be able to work as a surgeon anymore. It’s devastating to realize what I spent so many years preparing for isn’t possible. I’m so depressed…” No one thinks they will ever be disabled even though statistics prove otherwise.

And so it happens that one day a member of the family becomes disabled and is unable to work. Since there is no financial contingency plan in place, claimants are forced to rely on benefits provided to them by their employers unsuspecting they could be walking the green mile to financial disaster.

Actually, I stopped counting the number of calls I receive from individuals who are perfectly trusting the system of private disability to provide for future financial needs. Most tell me, “I have a policy from my employer and I’m eligible to receive benefits.”  Or, “I’ve been paying premiums for my Individual Policy for over 28 years; now, it’s time for them to pay me.”

To begin, private disability insurance isn’t an “entitlement” and benefits are not automatically approved and paid. Insurers have complete discretion to decide who gets paid, who meets the definition of disability, and who doesn’t. There is an entire set of criteria including eligibility provisions, pre-existing condition provisions and definitions within the policy that are adverse to potential claimants before claims are even filed. Unfortunately, since most claimants do not obtain copies of their Plans or policies upon enrollment, it is impossible to defend what claimants do not know.

To depend on benefits that are uncertain is what I call a “family planning presumption of uncertainty.” Most group disability insurance provisions are designed to pay for limited periods of time. For example, the change of definition after 12, 24, 36 or 60  months presumes claimants are able to do at least sedentary work full-time. Group Plans aren’t intended to pay to age 65 since there are multiple contractual hoops to overcome long before claimants arrive at maximum duration of claim. Mental illness and self-reported claims are also limited to 24 months of payment. In fact, everything about a group disability Plan screams limited periods of payment. And, it’s the claimants responsibility to make sure they understand what they are entitled to, and for how long.

Every middle class family should have, or at the very least thought about, what their contingency plan would be if a spouse were unable to continue working. If a mortgage was approved based on the income of both spouses, then it should be assumed that it takes two incomes in order to pay the bills. If one spouse is forced to stop working for a medical reason, then what is Plan B? Unfortunately for most, Plan B is, “Well, I have this disability policy that will pay 60% of my salary, and we can keep going with that.”

Yes, but what if the insurer denies the claim? Then what? This is the part claimants never seem to have an answer for and they begin to walk the “green mile” to financial disaster, if not immediately, eventually. Houses are sold, assets are disposed of, retirement plans are exhausted, and unfortunately health insurance become unaffordable. Then what?

Claimants and insureds need to give some thought to future outcomes long before a disability happens, but using accurate information and perimeters for their decisions. Although available to most employees, private disability insurance should never be relied upon long-term for financial security. The risk normally assumed by insurers is transferred to claimants and insureds who now risk not getting paid at all.

Consider. Disability insurers make profit from NOT paying claims. Policies are contracts of “adhesion” meaning you have little to no say what the provisions are, and cannot negotiate terms. Even when insurers have the fiduciary duty to protect the interests of insureds, relationships between insureds and insurers is more adversary than fiduciary.

I’m asking my readers to give some thought today to their own Plan B contingency plans. What will you do if your disability insurer suddenly denies future benefits? Even if you’ve been receiving benefits for many years there is no “safety zone” and claims can still be denied. Be prepared. Those who tell me, “I don’t know what I’d do if my benefits were denied’, should start thinking about what resources would be available to them.

Please don’t allow yourself to walk the green mile to financial ruin. Plan ahead and have a contingency plan for the future. Disability insurance isn’t the save all solution to long-term financial planning.

Paperwork1A growing trend among disability insurers is to complicate the claims review process with more and more paperwork causing insureds and claimants to wonder if any amount of documentation is sufficient enough to pay claims. As a result, the disability claims process is exhausting due to the preponderance of medical, financial and occupational information requested by insurers on a frequent basis.

In combination with claims handlers who “make it up as they go along”, the process is overburdened with requests for individual and physician statements, questionnaires, activities logs, POF forms, Authorizations, tax returns, CPT/CDT codes, job descriptions, Training, Education and Experience Forms, and harassing letters that require responses. Anyone who is currently receiving disability benefits can attest to the fact that as soon as one set of paperwork is sent in, another one arrives just behind it.

What is interesting is that if you check the “proof of claim” provisions in your disability policy, most of the paperwork insurers ask for isn’t listed or required. Although most insurers “bully” insureds into thinking they need to provide additional paperwork in order to “cooperate”, the truth is insurers administratively “author” new forms to meet an internal need based on sets of protocol objectives.

For example, the Training, Education and Experience forms provide information used internally to conduct Transferable Skills Analyses at the change in definition after 24 months. The form isn’t required by the policy, but insurers will beat up on claimants if they do not provide it. In fact, most paperwork provided to insureds and claimants to fill out represents out-of-contract busy work so that insurers have an endless flow of information they can use to deny claims.

The most common mistake made by insureds and claimants is to literally “fill-in” every possible free space on insurance forms with as much information as possible. I’m sure the thought here is that “the more information provided the more credible the claim appears to the reader.” In reality, the opposite is true; the more information given to insurers the more documentation there is to dispute. The common thought by most insureds, “If I’m honest and tell them everything, my claim will be paid” is nothing more than a fallacy when one considers the lengths most insurers will go to deny claims that really should be paid.

DCS, Inc. supports honesty and truthfulness when completing all insurance forms. Still, insureds do not need to give away the farm.

Some insurers develop very interesting paperwork systems such as DMS that now has different colored forms larger than the standard 81/2″ x 11″ size paper. The company demands you send back originals because of the color coding. This leads me to believe that not all DMS files are electronic because color coded forms wouldn’t make any difference in a scanned electronic transmission of forms. Years ago Unum insisted on tabbing all of its paper files – red for medical information, green for financial, yellow for vocational etc.. Tabbing files was of course was eliminated when Unum installed better technology and opted for electronic transmission thanks to Tim Arnold’s war on Unum’s paper costs.

Companies such as CIGNA and Aetna have yet to catch up to technology and often have difficulty scanning in documents from a CD. Administratively, some insurers do not have processes in place to handle all of the paperwork asked for. MetLife, CIGNA and Aetna are infamous for “not receiving” paperwork sent by physicians and claimants.

What most claims handlers may not realize is that the majority of paperwork required by their managers (and companies) is intended to keep them on their toes. The absolute worst thing that can happen in the claims review process is to accumulate backlogs of claims that are not “looked at” or “touched” for long periods of time. Although this oversight might be good for insureds since their claims are literally left alone, backlogs are viewed by management as “lost profit” and are to be avoided at all costs.

One of the ways in which management can force claim specialists to “touch” claims more often is to require that certain paperwork be present in the claim file. Required lists of paperwork usually consist of: POF forms, verification of SSDI application, Training, Education and Experience forms,  and more recently SSDI files. Frequent manager claim audits (including Unum compliance) can identify how well claims handlers are keeping up with “touching” files. Most internal claims review processes require claims handlers to engage in “some action” on every claim file in their block every thirty days. Flups (follow-ups) are assigned to each claim in order to keep up with the frequent demands for paperwork.

In combination with requiring claims to be “touched” (viewed) every thirty days, insurers with malingering paranoia also create a long list of other forms that can be used by claims handlers when the old standbys have already been obtained. Activity Questionnaires fill in the gaps when there is literally “nothing else to do on a claim” and management is happy once claim backlogs are curbed to manageable levels.

Disability insurers tend to conveniently forget that those who file disability claims are ill and have limited capacity to complete forms, write letters, and respond to multiple phone calls per month. Many take medications that may affect verbal and written responses that shouldn’t be relied upon. While insureds are often unsure and unknowledgeable of the claims process, companies such as Sun Life have 25 page STD/LTD application forms it expects new insureds to fill out. Northwestern Mutual has a 5 page update form. It has often been suggested among my peers that excess paperwork is deliberate and is part of an agenda leading to non-payment of claims.

Although my opinion is that excess paperwork results from insurance paranoia that all claimants are malingerers, the claims review system is overpowering and confusing to those who are disabled and should be simplified. My guess is that insurers won’t “keep it simple” because they make too much money from it being complicated.

As the maze of paperwork continues, insureds and claimants find themselves paper shufflers at times when their focus should be on managing disability and regaining health. There is absolutely no question that the amount of harassing paperwork demanded by an industry supposedly dedicated (if you believe most of their marketing material) to the well-being of disabled workers, is designed not to make it easier for insureds, but to assist management in paying as few claims as possible.

Bottom line, there is no end in sight to insurance paperwork and harassing requests for more information. Unfortunately, “documentation” is part of the disability claims process and insureds are forced to divert time and energy from health needs to providing the same old information over and over again. I’ve said many times that insurers actually know very little about “disability”.

Complicating the system with burdensome and unreasonable demands for paperwork does NOT in fact help disabled persons at all.



Unfairjd of Erick, OK on Sept. 29, 2014

I pay premiums to keep myself and family safe. When I was injured, Unum played a word war with my policy. When any one word was out of place, the investigation was stopped. When the situation was handled it would return to active status until another word would be found to be misspelled or inaccurate at which time investigation would be inactive until that was solved. It repeated itself for months on end. Unum would look for every reason possible to not pay a claim. How these people live with themselves is beyond me. I hope at some point, either one of their employees are a family provider for one of people that handled my case has an injury or death and has to suffer the humiliation I was subjected to. If you have a policy with Unum, do you and your family a huge favor and look elsewhere for insurance.

Cindy of Omaha, NE on Sept. 26, 2014

I’ve lost count on how many times Unum has contacted me – contact included day of surgery, two days after surgery. Today I was called and had to wait on hold when I returned the call. I was asked if my return to work day was the day they provided – I said yes, I’ll just use vacation time for the rest of my needed time off. I want to recuperate without the hassle.

carmella of Akron, OH on Sept. 17, 2014

Had a hysterectomy. My doctor said that I could return to work 6 weeks post op with a 10lb lifting restriction. She also informed me that I would have this restriction for 3 months. My employer informed me that I couldn’t return to work with any restrictions, being that I’m a physical therapist assistance, there would be nothing for me to do and I would definitely have to lift more than 10lbs. Unum refused to approve my claim. Not only did they refuse, my doctor had to fax forms to them several times before they processed the claim because they said they never got them. Come to find out, the papers were scanned into the wrong claim. I’ve had nothing but a complete bad experience with them. They have caused so much stress that I had to be put on medication for depression. Not how you help someone who’s just had surgery and is in pain.

Elaine of Bellflower, CA on Sept. 16, 2014

I signed up for benefits through my employer. I signed up for the standard plus plan. Unum does not respond on time, does not pay on time. I gave them permission to obtain ALL the paperwork necessary for them to do their job, and I still have to recover and send them (pay out of my pocket exp) the information. Now I am receiving retaliation response because I turned them into my benefits main office and they were investigated.

Tiana of Milwaukee, WI on Aug. 28, 2014

My doctor took me off of work for medical leave on 8/2/14. Two weeks before I knew that I was going to be off, I contacted UNUM to get the proper documentation that needed to be filled out in order to approve my leave. My doctor filled out all of the forms and I faxed them to UNUM. After about 10 days, they decide to say that they need additional documentation from my doctor (but never contacted me to let me know. I only found out when I called to check the status). I had my doctor send them the information that they needed. After another 15 days, it was almost time for me to go back to work. They stated that they have up to 14 business days to make a decision. With all of this, I was off of work for a whole 3 weeks with NO pay and was almost a month behind on all of my bills. Today is the last day that they have to make a decision (the 14th day) and when I called they said that they are “actively working on a decision as we speak”. I will definitely be filing a complaint once the decision is made.

Marilyn of Lakeville, MN on June 23, 2014

Unum administers my company’s FMLA, STD, and Cancer insurance. I was diagnosed with FIGO, Grade 3, Clear Cell Uterine Cancer, as a result of the genetic disease Lynch Syndrome in February and referred to the Mayo Clinic in Rochester. Unum started harassing me within 2 weeks of requesting FMLA. The paperwork that they wanted was never sufficient for them. They wanted my team of doctors to tell them when I would be back to work when I had not even started radiation treatments. The first 90K bill I sent to Unum, they paid $865. When I phone the woman could not pronounce the word Mayo and explained the they would pay only on my CT scan since a sonography is not the same as an ultrasound. They did not pay of the full surgical benefits stated that they do not pay on frozen surgical units. As a patient with Lynch Syndrome, the units must be frozen for testing.

Unum has now revoked my FMLA. They have sent me letters and left messages on my phone stating that NO FURTHER MEDICAL TREATMENT IS REQUIRED. National Cancer Guidelines for Clear Cell Cancer and Lynch Syndrome state doctor follow up every 3 to 4 months for the first 3 years, twice a year for the 4th and 5th year. Colonoscopies every 1 to 2 years. I am now waiting for Unum to tell me when I can expire.


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