“Regular care” is the frequency of medical consultation and treatment recommended for each impairment that is reasonable to sustain wellness, Maximum Medical Improvement, or control and treat disease. For example, Mr. X informs his insurer he is totally disabled due to depression and anxiety and is unable to do his job. He reports he sees his therapist every other month.
Consulting with a therapist every other month would not be considered “regular care” since an individual who is depressed sufficient not be able to work should be in counseling a minimum of twice a month, and preferably once a week. Quarterly visits for mental health counseling for a disability severe enough to cause cessation of work is NOT considered regular care. Standards of care are set by the American Psychological Association and the DSM-V.
Another example perhaps would be Mr. B. who is diagnosed with chronic back pain and who consults with his orthopedic and family physician once a year. Mr. B. is also prescribed opiates for pain. Any patient who is taking narcotic, or opiates for pain should seek consultation and treatment frequently. Physicians who prescribe such medications usually make it a point to actually “consult” with their patients before renewing prescriptions for pain narcotics. Disability insurers would view yearly visits as outside of the perimeters of “regular care.”
This brings up a good point about pain management. For some, there may come a point when orthopedic conclude, “There is nothing more we can do for you” and we recommend you go to pain management. Insurers do not accept the rationale of “there’s nothing more we can do for you” when it comes to regular care. Insureds and claimants must still consult and seek treatment from family physicians or pain management facilities on a regular basis. Yearly treatment isn’t reasonable for claimants who report their pain is severe enough not to work.
Treating physicians can actually nip the “regular care” requirement in the bud by documenting, “Based on my medical treatment and history with this patient I have determined that quarterly consultation and office visits are appropriate and regular care.”
“Regular care” is objectively proven with the submission of patient notes which is why most insurers insist on requesting them. Patient notes contain records of when claimants were seen, how often he/she was examined, and outcome. Those who cannot produce patient notes (proof positive of regular care) are said “to have fallen out of regular care.”
Insureds should always keep in mind that without regular visits and medical consultation there is no disability claim.
What are Unum’s physician salaries?
This is a real sore spot for Unum management since internally it is preferable to create what I call “competition envy” among its physicians. One of Unum’s former medical directors told me that physicians are strongly cautioned not to discuss their salaries or yearly bonuses with each other. Not all physicians receive the same yearly bonus percentage. My opinion is that those physicians who deny more claims and are able to support Unum’s internal protocols are given more money as incentive. This is the one issue Unum is very sensitive about and I get the impression that if physicians were aware of the monetary discrimination, there would be internal upheaval.
In the past, I’ve said that the average ball park salary figure for Unum physicians is between $150,000 and $250,000 per year plus incentive. Realistically, Unum doesn’t allow specific information about salaries to go public even though it could be available otherwise on the Internet.
In my opinion, it’s not the amount of money Unum physicians are paid, but the fact that Unum’s physicians, or any insurance physician, parks his/her medical ethics at the door in order to misrepresent medical information in a way that supports the insurance agenda. If you ask me, insurance physicians cause harm and ignore the oath of their profession. I can’t imagine what it must be like to train for so many years to become a doctor only to trade Hippocratic for Hypocrite to benefit an insurance company.
I found this wording in my Unum claim file: “Clmt is dx with FMS and is td own occupation pending CID.” What does it mean?
Argh….UNUMSPEAK. It means, “Claimant is diagnosed with fibromyalgia and is totally disabled from performing her own occupation pending change in definition.” The writing means that the claims handler will pay and manage the claim until the change in definition when the “plan” to deny may change.