In the 1991 movie JFK, Kevin Cosner describes an US conspiracy to assassinate the President as “black is white, and white it black.” Like the movie, American disability insurers have created strategies to convey information concerning internal medical reviews that misrepresent what the process really is. In fact many insureds and claimants are under the impression Unum’s medical department reviews patient files looking for proof of disability. Nothing could be farther from the truth.
Unum’s hierarchy of medical review begins with a walk-in to a Registered Nurse followed by reviews by a OSP (Office Staff Physician), and finally a Medical Director. Since Unum pays its internal physicians to use their “board certified” credentials to legitimize its conclusions, multiple levels of medical review sends messages to regulators the company is “trying to be fair.” Unfortunately, “fairness” is not one of Unum’s attributes, and its internal review process is more of a “stacking of the deck” rather than a fiduciary deciding “indeterminable issues in favor of insureds.”
In fact, Unum threw “fiduciary duty” out the door a long time ago since the relationship only exists between Unum and ERISA policyholders. Insureds with regular DI claims have no such relationship but rather are aided by state consumer protection laws and legal venues for “bad faith.” With no state or federal agency “on call” to police Unum’s ERISA fiduciary duties, ERISA claimants are fair game in the Unum turkey shoot of medical review.
Most insureds and claimants are of the mistaken opinion Unum’s internal medical review is for the purpose of determining disability, or legitimizing claims through medical reviews completed by qualified physicians. Actually, Unum’s medical reviews are not looking for “disability” or evidence of impairment, but proof of work capacity. The process involves obtaining patient notes which are much easier to misrepresent with a process called “snatching.” This process locates key phrases and words favorable to the insurance company at the expense of all else in the record.
Key medical phrases obtained from patient notes are then “interpreted” and/or misrepresented to form medical opinions which are totally inconsistent with information contained in the record. For example a typical Unum denial letter might say:
“Information obtained from Dr. Smith indicates claimant is not able to sit or stand for more than 1-15 minutes, and pain on the comparative scale is reaching 8 out of 10. Claimant is restricted to non-exacerbating physical activity until further evaluation. Claimant is not reliable to return to work and has less than sedentary capacity. Otherwise, claimant says she is hanging in there and doing well.
However, medical review by our “board certified” physician indicates there are no documented medical restrictions and limitations precluding claimant from working a full-time sedentary occupation. There is no indication in patient notes that the treating physician conducted a full physical examination and therefore records indicate ability to return to work.”
Unum’s denial letters also border on the ridiculous such as the one I received today:
“Our first physician concluded, following the attempted contacts with your providers, that she disagreed with those who continued to support restrictions and limitations that would prevent you from performing your occupation. Give the disagreement, a second physician then reviewed your entire file to assess whether our first physician’s determination was correct. The second physician agreed with the first regarding your ability to physically perform full-time mostly-seated work. “
A characteristic of Unum’s medical review is that each internal physician agrees with the review below it. Does having a second physician agree with a distorted medical review really lend credibility to the review? I think not. The above language makes Unum’s conclusions appear silly and obvious as to what the real motivation is.
Did the physician’s patient note really say that? The purpose of Unum medical review is to create an illusion of credibility by “inventing” medical consensus of opinion that really doesn’t exist. Multi-level medical reviews moving up the credential ladder further suggest to regulators that Unum’s conclusion are the only ones to make. In reality, Unum’s medical reviews are “hogwash” and the company knows it.
Unum’s bogus medical reviews tend to keep insureds and claimants on the hot seat constantly “correcting the record” with more and more medical information. While treating physicians are constantly informing Unum, “I didn’t say that”, and claimants are asking, “How can Unum allege I’m not disabled?”, the company is raking in more and more profits from its own violations of medical ethics missed by regulators.
Unum’s medical review strategies are actually pretty clever. Prudential, for example, denies claims based on the say-so of unqualified registered nurses which is an obvious intent to take the cheap way out. In contrast, Unum goes to extraordinary lengths (and costs) to create an illusionary record of medical review, appearing legitimate, but in reality little more than an illusion obtained from snatching phrases from patient records.
Unum medical reviews include outsourced IMEs with physicians who support the company’s agenda as well as internal physicians who are paid annual percentage bonuses to support Unum’s script to deny more claims. Those insureds who believe Unum is acting in their best interests are ill-informed as to Unum’s conflict of interest in misinterpreting medical information. The company isn’t looking to pay claims, but to deny them in a way that looks good.
Unum’s internal physicians learn the claims lingo and strategies to perfection. Drs. Ursprung, Ball, Neuren, Szatalowicz, Heimonen and many other Unum claim killers become proficient inventors of what patient notes mean rather than what they actually say.
As a consultant I’ve always questioned why attorneys and ERISA litigators don’t point out the discrepancies between what medical records actually say and Unum’s interpretations as to what they mean. It seems reasonable to me that if Unum’s medical reviewers are deliberately misquoting and misrepresenting patient notes in order to meet profitability targets, it would be important to mention in litigation. Most of Unum’s medically unsound medical interpretations are obvious.
For example, a neonatologist with HIV/AIDS who had three MIs (heart attacks) and several stents placed does not have work capacity, but Unum said he did. Then of course, there was the case of the heavy truck driver with one foot Unum claimed could operate his 16-wheeler with only one leg. Let’s not forget the heart transplant insured with an Ejection Fraction (EF) of 15% Unum alleged could load and unload delivery trucks. Or, perhaps the addicted anesthesiologist Unum claimed could go back to work in the surgical arena where opiates are readily available. None of these Unum insureds were actually able to return to work, even when Unum denied benefits alleging they could return to work full-time.
Unum’s medical opinions are focused on getting insureds and claimants off claim by exercising a conflict of interest supported by internal strategies deliberately designed to look credible. The cost of providing such an internal mechanism to produce profit is probably in the millions.
Armed with the knowledge that Unum’s medical review does NOT support recommendations from treating physicians, insureds and claimants can take proactive steps to make it difficult for Unum to misinterpret and “snatch” information to its own benefit.
One of the most important actions Unum claimants can take is to have conversations with all treating physicians concerning the content of patient notes. In reality, patient notes are not intended to support disability and are merely “physician scribbles”, or reminders to the physician of treatment and consultation. The accumulation of patient notes constitutes a “patient history” and represents the only record of medical treatment.
Treating physicians can be requested to document patient records to include: diagnosis, prognosis, medical restrictions and limitations, statements as to whether patients are at MMI (maximum medical improvement), and descriptions of treatment plans. All Unum insureds and claimants can inform physicians they are receiving disability benefits and the need to proactively document patient files. Treating physicians actually have more authority and power over disability determination if they choose to enforce and stand by their diagnoses and treatment plans with adequate documentation.
Claimants may also discuss Unum’s practices with their physicians. All too often patients themselves place their physicians on pedestals and are too afraid to bring up the subject of disability claims and how physicians can help. Patient medical records belong to the patient, and those who are receiving disability benefits should always discuss how important it is to do a good job documenting diagnosis and treatment in the patient record.
In the end, Unum’s medical reviews, conducted by internal physicians paid to support a denial agenda are little more than hogwash. It remains up to insureds and claimants to ensure patient files are specifically documented and accurate.
Insureds and claimants would do well to remember that patient files never say what Unum says they do, nor is Unum’s consensus of medical opinion an accurate assessment of medical disability. Unum Group’s ability to launder medical records just might be a deliberate “pattern of practice” equal to RICO (assuming a group of attorneys ever get around to it.)
Bottom line? Deliberately devising strategies to misinterpret/misrepresent medical information from patient records is an unfair, if not an illegal, claims practice. Always discuss Unum, its claims practices, and the need for patient documentation with all treating physicians. Unum’s medical reviews are hogwash and everyone knows it!