Friday Recap – The Week’s Most Important Issues

(Please note this is a new category containing a weekly summary of issues brought to our attention.)

Despite several Lindanee posts concerning phone conversations with insurance companies, nearly all those who contacted me talked about contacting their claims representative on the phone. From a consultant’s point of view I can only mention, suggest, recommend, reiterate, and post so often about the risks one takes when speaking with insurance representatives on the phone. Unum, for example, has an ongoing company initiative to engage dialog for the express purpose of finding out about daily activities to determine how they equate to work capacity.

Those who follow Lindanee’s Blog on a regular basis are aware we do not recommend verbal communications with any insurance company on the phone. Still, I see quite a few comment posts on the blog talking about “contacting my insurer.” Insureds have the right to request all communications in writing. Anyone who is ill and taking certain medications probably shouldn’t be communicating on the phone with the insurance company anyway. If your disability claim was any other type of retail sale, I’m sure you would insist on obtaining communications in writing.

I clearly understand why claimants and insureds contact their claims reps on the phone when they know they shouldn’t – it’s to obtain reassurance about something; to do everything and anything possible to take away the stress and worry experienced at that particular moment. It’s actually pretty normal for someone to have such a heightened sense of stress and worry that no matter what the risk, he/she must be reassured. Calling the insurance company is the most direct way to calm that need.

While I understand the emotional reasons for wanting to be reassured, I also understand how very simple conversations with insurers can turn into a “chat” resulting in a denied claim. The only time DCS, Inc. recommends a verbal exchange on the phone with insurers is to ask the question, ” Can you please tell me when I can expect to receive my check?” Please think carefully about your phone calls to claims reps and insist on written communications only.

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Although I’m not going to share the actual posts, there have been several Unum employees who took issue with my characterizations of them and their jobs at Unum. I have to say that it might not be a good idea to send posts to Lindanee’s Blog from a @unum.com email address. Unum monitors the emails of its employees. If there are any Unum employees out there reading this, it might not be a good idea to send nasty emails to me from your desk at work. You may get into trouble.

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Unum’s G4S is apparently contacting insureds by phone claiming all they want is to “have a conversation.” Calls may be connected to surveillance attempts. Claimants need to be aware of G4S and The Hub private investigation services. Insureds and claimants have no obligation to speak to private investigators on the phone. If there is no contractual duty to meet with a field representative, and the insured respectfully declines “the meeting” it makes sense to me Unum’s reps might try just calling to get the same information. Omission of a contractual duty also applies to phone calls with field reps.

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Disability Insurers and Actual Psychotherapy Notes

In the last several months claimants have contacted DCS, Inc. with several issues dealing with Unum’s harassment of mental health providers to obtain actual psychotherapy notes. Although there are several other Lindanee posts on the subject I think the topic deserves a re-mention.

Unum’s general Authorization to obtain information specifically excludes actual psychotherapy notes in its wording. In other words, Unum claims handlers may not use this Authorization to obtain therapy notes from any mental health provider. However, Unum (as do other insurers) does indeed have another version of its Authorization which is specifically for the purpose of obtaining psychotherapy notes. Most Unum claims handlers are unaware they can’t use the general Authorization to obtain mental health information, AND mental health providers do NOT often read the Authorizations they get, therefore unfortunately, Unum is able to obtain very personal information about its insureds.

First of all, let me say that there is no contractual policy provision requiring the submission of actual psychotherapy patient notes as proof of mental and nervous claims.Disability policies contain no such proof of claim requirement. The reason why insurers demand “the notes” is because it is easier to engage in a practice I call “snatching”. “Snatching” is a strategy insurance medical reviewers use to “pick up on” and “snatch” key words and phrases favorable to its non-compensable objective, at the expense of all else contained in the record. Actually, one could cite the same “snatching” possibility from regular medical patient notes as well.

By its very nature, receiving therapy requires insureds to share very personal and often intimate information with their therapists. This information could include trans gender or sexual preference information, fertility counseling, feelings concerning sexual or physical abuse, and other issues not even relevant to the claimed disability. If it were known in advance disability insurers could gain access to actual therapy notes, patients may not share information about themselves openly and honestly with their mental health providers and therapy would be of no or limited value.. I’ve had insureds tell me that they withhold information from their psychiatrist because they suspect Unum may gain access to their actual psychotherapy notes.

In the last five years state laws and HIPAA have changed considerably giving mental health providers greater control over their psychotherapy notes. It is generally presumed psychotherapy notes are the property of the therapist and are written as an aid to the provider in the ongoing treatment of their patients. Although there are some psychotherapists who keep prestigious notes, there are others who may only write down a few words for each session. In any case, psychotherapy notes are NOT intended by the physician to document disability in a way accepted or required by insurance companies. Actual psychotherapy and/or patient notes and certification of disability are two different things and are never intended by the author to document disability.

Mental health providers are NOT required by any authority to give up their actual psychotherapy notes to insurance companies. There remain some situations wherein the state or federal government may subpoena records in the case of child abuse and litigation etc., but certainly an insurance company such as Unum cannot demand psychotherapy notes at any level as proof of claim, nor can any company threaten to deny claims if the psychotherapy notes aren’t released. That said, most disability insurers will beg, harass, and threaten on those occasions when actual psychotherapy notes are unavailable because these companies know the notes contain valuable information which could be “snatched” to validate a claim denial.

Please keep in mind that although actual psychotherapy notes are not required as proof of claim, proof of claim is required from mental health providers. Mental restrictions and limitations can be provided to insurers in summary form, i.e. filling out narrative forms, letters and answering questions when submitted in writing.( This excludes doc-to-doc calls!) Insureds should be careful because some mental health providers prefer to take the easier route by sending actual psychotherapy notes rather than filling out 5 page forms even when the Authorization they are presented with specifically excludes psychotherapy notes. As one psychiatrist put it this week, “These forms are a waste of paper.” Really?

Insureds and claimants have the right to designate actual psychotherapy notes as Protected Health Information “PHI” under HIPAA. Unum and other insurers are famous for claiming, “HIPAA doesn’t have anything to do with disability claims”, and it really doesn’t. But HIPAA does have everything to do with the voluminous amount of medical records that go flying back and forth from health providers to insurance companies electronically or otherwise. So yes, HIPAA does apply when insureds are speaking specifically about protecting their mental health information.

Finally, psychotherapists have a great deal of authority and control when it comes to releasing or not releasing their own therapy notes. Vexatious calls and harassment from insurers to obtain actual psychotherapy notes can be immediately nipped in the bud with the statement, “While I am happy to provide my patient’s insurer with mental restrictions and limitations in summary form, I do not release actual psychotherapy notes to any outside third-party. Should you need updated information, please submit your questions or forms to this office in writing.” This should take care of any repetitious phone calls or requests for actual psychotherapy notes. Some psychotherapists complain about the harassment from insurers, but really need only to make the above response.

In summary, insureds and claimants need to consider the consequences of releasing actual psychotherapy notes to insurance companies. Once this or any other medical information is released it loses its HIPAA protection anyway. (Read the HIPAA compliant Authorizations, it tells you that.) Speak frankly with your mental health provider and together decide how to handle requests from your insurer for actual psychotherapy notes. As a mental health patient you do not have to give permission to your therapist to release actual psychotherapy notes, and insurers cannot threaten to deny a claim because the notes weren’t provided.

Of course, insurers won’t give up on this fight easily since insurance companies are well aware of the financial value of “snatching.” Keep in mind it is insureds’ responsibility to make sure mental restrictions and limitations are provided to the insurance company in summary form. Insureds and claimants still have a responsibility to provide proof of claim, but it doesn’t have to be in the form of actual psychotherapy notes as insurers allege. In order to stop vexatious calls therapists need to know they can step up to plate and put an end to the multiple calls by responding as suggested above.

Psychotherapy is personal; it’s intimate; and its value to the insured depends on its remaining so. Although insurers are entitled to information certified by mental health providers it is not a contractual duty to give up one’s privacy when information can be given to insurers in summary form. Those who have disability claims are subjected to privacy invasions as an inherent part of the process to begin with. However, insured’s intimate life’s details and personal feelings such as those shared with therapists need not be divulged to support a mental a nervous claim despite insurers’ unreasonable attempts to obtain it.

MATRIX and SSDI – A Perfect Situation for a US Senator

There are undoubtably many complex situations which can arise from SSDI primary and family offset provisions contained within disability claims. Most ERISA group STD/LTD policies now contain provisions allowing the insurance company to reduce (offset) for monetary awards made by social security. The intent of the offset is to prevent claimants from receiving BOTH SSDI and disability benefits which together exceed  pre-disabilitiy income. It would not be fair for someone to actually make more money disabled that if working.

However, there are issues which can arise due to complicated family situations that do not make any reasonable sense at all. For example, recently one of our clients notified us MATRIX refused to remove a dependent offset from her monthly disability benefit. Our client was divorced some years ago, and is not the custodial parent of her son who turned 18 in June of this year. Our client’s ex-husband is also disabled and receiving SSDI. He was issued an SSDI award letter for himself AND his dependent son.

In the meantime our client presumed her son received SSDI benefits under her husband’s SSDI award. She received no benefit from any money awarded to her son over a period of years. MATRIX attempted to also offset pension benefits received by this client which she had immediately rolled over into    retirement plan. When notified, MATRIX did remove the offset for her pension, but continued to offset for the dependent award of her son who was in custody of her ex-husband and who also benefitted from her son’s SSDI award.

MATRIX refused to remove the SSDI offset for our client’s son alleging the dependent could receive benefits from both his mother’s and father’s SSDI awards. Of course this isn’t true. When challenged, MATRIX claimed it consulted an expert who advised our client’s son could have received a dependent award under his mother’s “record” which was “awarded” to her ex-husband. MATRIX demanded my client go to Social Security and obtain a letter stating under which “record” the dependent award was made.

Sure enough, SSA granted the dependent award under our client’s “record” but awarded it to the husband and included the dependent on the husband’s award letter. According to SS, when both parents are receiving SSDI, the dependent award is counted under the “record” of the spouse receiving the lesser SSDI benefit. Where does this leave our client? My client must now pay MATRIX back $32,000 in overpayment for a dependent award made under her record. She was never the custodial spouse, nor did she ever receive any money for any dependent. Since her husband is actually an ex-husband, it is unlikely any assistance paying back the overpayment will come from him. Our client’s disability benefit has been reduced to $0 until the overpayment is repaid.

In this situation MATRIX attempted to offset for a retirement benefit which it was not entitled to. This mistake was corrected. Our client has been penalized by MATRIX because the policy says the company can offset SSDI benefits received or “entitled to”. To my knowledge not even Unum penalizes a claimant for dependent benefits received by an ex-spouse. In addition, MATRIX also is attempting to offset for the dependent award AFTER he turned 18. When questioned about it, a MATRIX manager said, “Well you didn’t tell us about it, so we didn’t know.” In  my opinion, any company who knows enough to offset a dependent award in this complicated situation should also know when a dependent turns 18.

This situation isn’t going to happen all that often, but when it does it will be devastating to the parent with the lesser SSDI benefit and who will be penalized by the disability insurer even when no real money is received. Although MATRIX may claim it has a contractual right to offset our client’s benefits it isn’t reasonable to do so in this complex situation and the company could apply logic and not offset our client’s benefits.  Of course MATRIX will offset our client and take her benefit. As to the issue of our client’s son turning 18, we now have to prove that fact before MATRIX will remove the offset altogether and compute the overpayment.

MATRIX is indeed a scoundrel and has actually threatened to report my client for fraud. The company probably won’t because it was reasonable for our client to presume her son’s SSDI award was taken from her ex-husband’s record since the son’s award was included on her ex-husband’s SSDI award letter. My client never knew her “record” was charged for the dependent award until she was asked by MATRIX to obtain a letter directly from SSA.

In  my experience I have never found MATRIX to act as a fiduciary to any claimant for any reason. Its activities resembling “grabbing” for offsets is unprecedented. In any case, this situation points out what can happen when families are divorced, both parents are receiving SSDI, with one non-custodial parent. One of the parents will be hurt financially. In my opinion this situation should be brought to the attention of my client’s senators since clearly the intent of the offsets is not to penalize a non-custodial, disabled parent. Changes to the law need to be made.

DCS, Inc. gives a swift kick to MATRIX for attempting to take offsets it’s not entitled to, and penalizing a non-custodial spouse when it is clearly not the intent of the policy or law to do that.

Air, Food and Water – What’s In It And Why Am I Sick? by Linda Nee

Last week one of your clients sent us an article concerning indoor air pollution and its effects on those who suffer from chemical sensitivity and encephalopathy from the environment. As I read the article and understood the implications of indoor air quality on those who are affected, it also occurred to me the quality of indoor air is not the only problem making Americans sick.

I have often asked myself the question, “If there’s a permanent cloud of smog pollution covering Los Angeles, why do people live there?” Americans have known for better than a decade the air we breathe contains a mixture of petroleum exhaust, chemicals, pollutants and a myriad of other toxins which enter the blood stream and affect the liver and immune system. Natural health enthusiasts eternally encourage “detoxing” because it a well-known fact humans are affected by the quality of air we breathe often to our own demise.

Despite a wealth of information regarding the quality of the air, ozone levels, and chemical sensitivities (which are increasing due to intolerance level saturation) Americans do not as a whole appear to be all that concerned with air quality.

At one time Unum Life Insurance of America made a commitment to its employees to provide “clean air” and spent a few hundred thousand installing an air filtration system in its buildings. Unfortunately, the good ol’boys from Chattanooga brought in different perspectives and claimed the air filtration system too expensive to maintain. UnumProvident employees began to get sick at increasing rates.

It does not surprise me to learn that there are those who are so severely affected by our polluted air (inside and outside) that permanent disability is the only option. Still, “bad air” is not the only problem affecting the American immune system and making people sick.

Although I love to watch Guy Fietti’s Diners, Drive-ins and Dives, I wouldn’t seriously eat the food which contains disproportionate amounts of salt, sugar, fat and pork. Those ”baby back” ribs might seem tempting, but in the end Americans often are not aware of how detrimental these foods are, or if they are aware, really aren’t concerned.

Granted, Americans have become more “label conscious” in recent years, but the average shopper who reads food labels, shrugs and buys the package anyway. One of the most dangerous chemicals in our cosmetics is propylene glycol, an organic form of mineral oil (petroleum product) found in automatic brake and hydraulic brake fluid and industrial antifreeze. This substance along with ethylene glycol (used in acrylic paints) is a strong skin irritant and can cause liver abnormalities and kidney damage. Try an experiment and check out items in your bathroom such as soap, shampoo, conditioner etc. and locate propylene glycol in the label. What you find might surprise you.

What is most disturbing about our food it that much of what we eat has been genetically modified with “genetically modified organisms” (GMOs). GMO modification is a process in which changes are made to the DNA of the vegetable or food to make it more resistant to pests, herbicides (Roundup), and other problems.

The culprit seems to be Monsanto who continues to produce GMOs. American food has been genetically altered since 1996, and although the EEC requires labeling of GMOs, in the US GMO labeling is optional. Foods containing the most GMOs are soybeans, corn, canola products, rice, cotton seed oil, papaya, and farm raised salmon. What most people do not realize is that Aspartame is genetically modified with E. coli bacteria and probably shouldn’t be consumed by humans. How about that diet soda?

Would you prefer to eat a tomato which contain a gene from a fish, or a potato with DNA from an insect? Although Monsanto alleges genetically modified foods are safe, it is also known DMOs can cause gastrointestinal an immune system disorders, accelerate aging and infertility. Truth is, in this country we don’t really know what we’re eating, and it’s making us sick to the point of disability.

Finally, there is the issue of drinking water. To remain healthy, humans require 6-8 oz. of pure drinking water every day. Unsafe water is often the cause of many diseases including malaria, typhoid, diarrhea, hepatitis A and intestinal worms. Remember as kids when it was ok to drink water from a tap? Although authorities continually claim tap water is ok, many Americans purchase filtration systems and buy bottled water.

60% of the world’s 227 biggest rivers have interrupted stream flows due to dams and other infrastructure further reducing water quality. I am reminded of a small Maine water district who suddenly announced to the community it “forgot” to add chemicals to the reservoir for a year. Yikes! Do we really know what we’re drinking these days? Can Americans be guaranteed pure sources of water in the future? Perhaps not.

It is obviously the combination of polluted air, genetically altered food, and impure water which is causing Americans to be sick. This in combination with years of over-taking antibiotics,causes me to wonder how our immune systems are able to protect us from the environment at all. Have you ever run into a friend who tells you, “Gee, I’m not feeling well today. There’s nothing wrong in particular, I just don’t feel well.”

It is NOT only indoor pollution which exacerbates chemical sensitivities, but a long list of chemical food additives, sulfates, animal antibiotics, water pollution, and other unhealthy environmental factors weakening our immune systems to the point of permanent disability. Many diseases such as Multiple Sclerosis, Lupus, and Diabetes can be the result of impaired immune systems caused by the air we breathe, the food we eat, and the water we drink.

In recent years, due in part to the unavailability of necessary health care, Americans have had to take more responsibility for their own health and well-being.  There is a great deal of information available on the Internet about GMOs and other health risks.

It certainly is worth your time to do the research and be well.    

 

The Impoverished Disabled Middle Class by Linda Nee

More and more disabled Americans are contacting DCS, Inc. with personal stories of disability claim injustices followed by denied appeals leaving them to support their children and families with social security income only.

An insured called to tell us CIGNA denied her appeal leaving her to support her son on the $1,700 she receives from Social Security. Her mortgage is $1,200. Although the reasons given by CIGNA for not paying the claim aren’t valid this insured’s only recourse is to convince an attorney to take her case – another situation contributing to the unfair disability insurance scams allowed in this country.

Although this insured’s policy is not subject to ERISA with a net monthly benefit of $1,200 her claim has already been bounced from one attorney to another. No attorney wants to take a case with such a low benefit amount thus throwing the insured and her son under the proverbial bus. Attorneys are literally leaving large segments of the middle class without representation, which is well-known to insurers who are looking to deny more and more claims.

In addition, one of the issues DCS, Inc. writes about publicly is when claimants and insureds are required to produce expensive vocational and peer review reports (requiring money the disabled do not have) in order to overturn appeals for benefits they are already entitled to.

From what we can gather there is no regulatory agency in the United States willing to actually investigate insurance complaints and provide consumer protection to those burned by major insurers. Nearly 95% of those who contact us yearly with state and federal complaints report the failure of any state insurance agency or department to actually investigate any insurance complaint.

It is now agreed among scholars and others in the industry Unum’s multi-state fine of $15 million was little more than a pay-off to states who agreed silently to “leave the company alone” and give them a free pass in the future. The EBSA, an arm of the U.S. Department of Labor, consists of bureaucrats who waste taxpayer money by advising poor ERISA policy holders to find an attorney and go to court. This agency of the federal government does not directly protect or support ERISA policyholders from insurers who deny claims unfairly.

Therefore, in the United States the operation and regulation of the disability insurance industry can reasonably be said to be somewhere between corrupt and no more than a scam for the following reasons:

1. Disability insurers are permitted by state regulatory agencies to deny claims unfairly by using “discretionary authority” as justification for doing so. There is an  inherent “conflict of interest” since each insurer is both reviewer and payor of claims.
2. Insured and claimant complaints are not investigated by regulatory agencies who prefer to give insurers a “free pass.”
3. EBSA, the federal agency paid to look out for ERISA claimants does not do its job.
4. Attorneys discriminate among disability claims selecting only the most wealthy benefits for litigation. This throws most of the disabled middle class under the bus since one of the major characteristics of “the American disabled” is that they don’t “have any money.”  As one attorney put it, “I’m not a charity.”
5. Denied insureds and claimants are required to have personal funds in order to pay for medical and vocational reports to perfect an appeal when they are legitimately entitled to benefits anyway. The National Association of Insurance Commissioners (NAIC) identifies strategies forcing insureds to go to court to obtain benefits as an unfair claims practice.

Unfortunately, the disabled middle class is quickly becoming impoverished by multi-million dollar insurer corporations, republican judges and legislators, scrutinizing attorneys, and blind federal and state regulatory agencies.

The next time DCS, Inc. receives a call from an insured family telling me they have been forced to live out of their car because Unum (or another insurer) denied their disability claim unfairly, I may be forced to consider protesting the issuance of disability insurance at all.

Clearly, employer STD/LTD plans are currently providing no permanent financial protection to the middle class. And, there is no guarantee any ERISA policyholder will have access to the courts without an attorney willing to take their case.

I find myself wondering where America went these days because it certainly isn’t here anymore. When a system impoverishes an entire class of disabled Americans, it’s time to take notice and find a means to fight back.

No one’s family should have to live in one’s car because they are disabled and can’t work.

 

 

 

Unum’s Deception About SSDI Files – A Necessary Read

Reader’s have often read posts in which I clearly state “insurance companies do not tell the truth.” Unum’s continuous harassment of insureds with requests to sign SSA releases to obtain SSDI files is an excellent case in point.

In 2004  state commissioners who reviewed UnumProvident’s unfair claims practices identified Unum’s strategy of forcing claimants to apply for SSDI and later terminating the same claims alleging work capacity as an unfair and egregious claims practice.  This process was and remains very profitable to Unum. Unum forces all claimants to apply for SSDI and when they are awarded benefits collects on the overpayment. Then, when the claim reaches the 24-month change in definition the claim is denied because Unum’s reps “identify alternative occupations the claimant can perform based on their training, education and experience.”

One of the worst things that can happen to a Unum insured is to receive SSDI benefits (at Unum’s urging) give back the overpayment, and then be informed the claim is denied after the “any occupation investigation” at 24 months. The insured doesn’t have the benefit of the overpayment, and no longer has a claim. If the employer integrated health benefits with LTD, the claimant no longer has any health insurance coverage either. Not good.

Therefore, as part of the multi-state settlement Unum agreed “to consider” SSDI awards when making its own liability decisions. (No other disability insurer has ever agreed, or has been forced to do this by any governmental body.) Although the multi-state settlement agreement did NOT specifically require Unum to force claimants to give authorizations to obtain the entire SSDI file, Unum found it to be to their advantage to obtain the file since SSDI decisions often contain additional information Unum can use to deny benefits especially if the claimant appeared before an Administrative Law Judge.

It is important for readers to understand if Unum strictly adhered to the multi-state directive to “consider” SSDI awards Unum might not be very profitable. Therefore, Unum had to devise some sort of internal strategy to “satisfy regulators” while at the same time neutralizing the effect of “considering SSDI awards” as proof of disability. Make no mistake, Unum and its management are experts at camouflaging internal unfair claims practices to appear credible when in reality they are not.

Here’s Unum’s current strategy:

• Force claimants to apply for SSDI even when it appears the claimants may not be eligible for federal benefits.
• Collect the overpayment to reduce the cost of claims.
• Convince and persuade claimants to sign authorizations to obtain entire SSDI files by informing them their request is “for their benefit” and that “Unum will give the information considerable weight when making their own liability decision.”  Obtaining the entire SSDI file may provide Unum with additional ammunition to deny claims while having possession of the actual file will satisfy regulators Unum is considering the information even though they are not.
• Follow-up with continuous requests for signed SSDI authorizations until the claimant gives in and provides it. Inform the claimant it is in their best interests to “give up” the file.
• Obtain updated medical information such as an IME, doc-to-doc call, or simply update medical information so that “more current” medical restrictions and limitations are in the file.
• Obtain surveillance of the claimant, most notably performing activities not allowed or restricted in the SSDI file.
• Deny the claim with the following rationale: “We do not dispute that she (the insured) was impaired at that time and have approved benefits beyond that date. However, we have received significant information since that time, which demonstrates that the insured has greater capacity than previously opined. This includes reports of her activities, medical records, surveillance and an IME, which serves as compelling evidence that the SSA award is inconsistent with the applicable medical evidence. Therefore, our decision differs from that of the SSA.” 

Remember this is AFTER Unum cajoled its claimants to apply for SSDI, demanded repayments, and harassed claimants to sign SSDI authorizations, “so that Unum can give claimants the benefit of the decision.” And by the way, “if you do not sign the authorization and we (Unum) cannot give the claim the benefit of the SSDI determination, Unum’s decision will be made using only the information we currently have.”

We all have to admit Unum’s strategy to remain complaint with the multi-state settlement agreement is very clever. The problems, however, are the misleading (if not dishonest) written communications made to the claimant claiming SSDI files will be used to the claimant’s benefit. DCS, Inc. has read as many as five Unum denial letters all claiming the existence of “more current medical information” invalidates its mandate “to consider” SSDI files before making their own decision. This means the current strategy to disregard SSDI file information where more recent medical information exists is most likely a company directive.

I’m sure there are many claimants out there who succumb to Unum’s consistent harassment to sign SSA authorizations to obtain SSDI files. Claimants are reminded there are no contractual provisions requiring any claimant to provide SSDI file copies as proof of claim. But of course, Unum doesn’t tell you that. Unum simply covers its behind with regulators by adding the SSDI file to the Administrative Record while at the same time neutralizing profitability losses.

Recommendations – Claimants should request their own SSDI files from SSA and read them. If claimants choose to send their files to Unum do not expect the company to actually “consider the award” and automatically pay benefits. Unum’s letters informing you the SSDI file “is to be used to your advantage” are NOT necessarily true. Unum can (not legitimately, mind you) inform you newly obtained information invalidates their multi-state requirement to consider SSA’s decision to award benefits.

Unum’s SSDI file request strategy, like many other areas Unum covered up over the years, is admittedly very clever, but misleading and untruthful. It would be very unwise for Unum claimants to take anything Unum communicates to them as the absolute truth.

Unum Claims Handlers Take Issue with Prior Post

This week I received feedback from Unum claims handlers regarding my prior post using words such as “ass” and “fool” which, believe me,  are no strangers to my UNUM SPEAK vocabulary. However, I have often viewed claims handlers in general to be victimized as well as the insureds who receive endless denial letters in the mail.

While I have never openly criticized Unum claims specialists for doing what they need to do to protect their jobs, I  have never supported the old excuses such as, “We don’t do that”, or, “ I don’t do that”, or”Unum doesn’t just deny claims.” There does come a point, in my opinion, when any intelligent, rational human being, working as a Unum claims handler cannot and should not, ignore what’s right in front of their face on a daily basis.

Most Unum claims handlers are at least aware of the Multi-State Settlement Agreement, Georgia Conduct Market Evaluation, California Settlement Agreement in which Unum was required to pay millions of dollars in fines and reassess roughly 250,000 claims denied between 1999 and 2004. Although Unum employees celebrated the end of the reassessment with cake and cookies, the Unum reassessment was no party and cost the company millions.

Although Unum’s management brain washes employees into thinking the current claims process is different, it’s my guess very few Unum claims specialists have actually read the Multi-State Settlement Agreement to determine for themselves whether the current claims process really is different and more fair. (The Multi-State Settlement Agreement can be located on-line.)

Daily manager harassment with IMT sheets in hand sounds a great deal like “targeting claims” and “let’s deny the biggest bang for the buck” especially when directors put names on the sheet identified by them or Quality Complaince. Just because claims handlers do not have access to financial reserves doesn’t mean Directors, VPs and Quality Compliance do not have programs that access the information. 

Any claim deliberately put on a list, or IMT sheet has already been targeted as non-compensable by those who represent the business interests of Unum. And… Unum claims handlers know it. Targeting claims is an unfair claims practice even when directors and  managers sell it as perfectly legitimate.

Unum consistently denies having claim financial reserves, but it would be impossible for Directors and VPs to roll in the profits they do without having some indicator or financial benchmark guiding the LAR or “Liability Acceptance Rate”. During the “exposed” years Unum’s management told regulators it paid 98% of claims, which if I had been a stockholder at the time, I would have immediately sold my stock!

In reality, Unum Group deliberately targets and denies claims at the expense of insureds and claimants solely for the purpose of bolstering profitability. Unum’s management also designs internal protocols, strategies and procedures creating the illusion of credibility that claims denials are appropriate. Unum’s management conjures up all this at their “offsite meetings”.

Unum engaged in unfair and egregious claims practices for a very long time and after the reassessment process when regulators were no longer looking, Unum redefined their “horses of a different color” and continued doing the same things the company was fined for previously.

Any federal or state regulator willing to sit down and actually look at Unum claim files subsequent to the Multi-State will be able to identify many of the same unfair practices Unum agreed to stop.

This information isn’t coming from Linda Nee by the way. There is sufficient public information available from other sources such as federal and state regulators to support Unum’s history of bad faith claims practices. The public no longer demands whistle blowers; it’s all a matter of public record.

Unum’s reorganization from UnumProvident to Unum Group didn’t change the public’s perception of Unum either. Unfortunately, Unum never lived up to its new marketing tact of “a people organization” and basically didn’t “walk the talk.”

No insurance company anywhere actually ceases to engage in unfair practices when these same practices have been determined to have been profitable in the past. Unum, in particular, simply renamed its departments and titles and went about their business.

Do Unum claims specialists know about all this? In my opinion, Unum DBS’ would need to be pretty blind and ignorant not to. Unum protocols are directly in their face every day; Directors are pushing the IMT sheets, ERDs must be met, and life at Unum goes on targeting and denying as many claims as it can.  And……………..Unum claims specialists are complicit in that endeavor. 

Let me ask our Unum employee readers a few questions. When your Director demands you deny this claim, or that claim, or  tells you to AP&C a claim on the spot, what do you think that’s all about? Do you think it’s appropriate for your manager to query your unit peers when he/she wants to gather information about you?

When was the last time you were forced to present a claim at roundtable? Do you think it is appropriate for Quality Complaince to demand a Unum Medical Director change his report to favor Unum’s denial decisions? Do you think it’s appropriate  to sign your name to letters re-written for you by your Director or manager? Do you not think the insured has a right to know who really wrote the letter with your name on it?

Again, while I have never criticized any Unum claims handlers for doing what they needed to do to keep their jobs, I absolutely do not support, nor do I defend the myriad of endless defenses raised by Unum handlers which they know to be entirely false.

Unum Group deliberately targets claims to deny them unfairly for profit. That’s a historically supported fact and Unum claims handlers know it. It’s also truthful to say Unum claims handlers will eventually be victimized themselves by the company if they challenge internal protocols,  are female, over 40, or become seriously ill.

My recommendation to Unum claims handlers is to research Unum’s history, read about the company’s unfair claims practices, and decide for yourself if what you are currently doing is different and fair. 

You owe it to yourself, separate and apart from what Unum tells you, to judge your own sense of fairness and ethical standard to what you have been asked to do as a Unum claims handler. 

Disability Claims Handlers – The Lowest Rung On The Chain Of Command

Less than 5% of insureds and claimants who contact DCS actually report having a good experience with their claims handlers.  In part, this stems from the fact insurance claims handlers and specialists are generally not afforded the autonomy to make decisions as they feel appropriate given the results of their own investigations.

Claims departments in general have several rungs of management hierarchy given approval authority and access to financial reserve information. Armed with knowing which claims have the largest financial reserve cost, managers and directors use their approval authority to manipulate which claims are paid and when. Contrary to what most insureds and attorneys might think skilled claims managers can manipulate the company’s profitability picture simply by denying “the biggest bang for the buck” and controlling the timing of claim approvals.

Obviously, if the insurance company pays more than 60% of claims it sells, a loss may be realized because premiums are based on a presumed 60% payout. This is why most insurance companies panic when the “liability acceptance rate” begins to creep above 60%. Managers and Directors of claim units are skilled manipulators of juggling high reserve ID claim approvals against ERISA poor reserves. Paying or denying claims is never as easy as just paying the claims that should be paid, and denying those that should be denied.

In most insurance companies claims handlers have no authority in making claims decisions and are little more than glorified administrative assistants. The job of a claims specialist is to push paperwork from one internal resource to another, gathering as much documentation as possible to “stack the deck” and support claims as non-compensable. It is extremely important for claims handlers to be able to “push” claims through the process of resource referral, identifying denials at an accelerated rate to avoid backlogs. Claims managers dread “backlogs” which are tragic to the process and set performance objectives and evaluation around how well claims handlers manage the claim assembly line.

Claims handlers are organized into units of 10 or less supervised by a manager or director. Each handler is assigned a “block” of claims” which can exceed 200 depending on how well the block is managed. Claims handlers receive 5-7 new claims per week, therefore if 5-7 claims aren’t denied each week, the “block” grows steadily until it is unmanageable. Becoming an experienced claims handler at most companies means the claims handler learned the skill, or knack, of denying the same amount of claims as enters the block on a weekly basis. Those who cannot “manage incoming versus out-going claims are terminated or asked to apply for other positions within the company.

Stress levels in most claim units are off the charts especially at the end of a month, quarter or year-end. It is at these times when there is a race to deny as many claims as possible. Directors get pushy and demand the denial of claims half-way through the claims process if it’s possible not to “shoot themselves in the foot.” While most of the general public is under the impression disability claims are investigated fairly, disability insurers are busy doing everything they possibly can to obtain as many internal paper reviews as possible to “get the damned claims out of here.”

Why? The answer is simple – to stack the deck with what appears to be credible paperwork sufficient to survive an appeal review. It’s not the initial denial that insurance directors pat themselves on the back for, but the denial uphold that comes later when an appeal is denied.( Mary Fuller, Vice President of Claims in 2002 never sent me a congratulatory note until the claim “passed the test of an appeal review” and remained closed.)

By today’s definition claims handlers are deliberately kept ignorant of the more complex claims issues particularly having to do with contract policy provisions. Despite the fact that most letters from insurers cite policy provisions over and over again, most claims handlers do not have a clue what the contract really says. A good example recently was when I asked a MetLife claims handler to identify the contract provision in my clients policy which gave MetLife the authority to only pay my client 50% of a total disability benefit. MetLife’s claims handler said he didn’t know, even though he pays my client every month at the 50% rate . He didn’t offer to look it up either, but I saved him the trouble by telling him there was no such provisional authority in the policy.

If the insurance company keeps claims handlers “ignorant” concerning policy provisions and financial reserves, they always have plausible deniability at depositions and trials. Attorneys always make the mistake of deposing claims handlers when the claims manager should really be the one on the hot seat. I’ve read many, many depositions where claims handlers’ responses are no more than “I don’t know….I don’t know….I don’t know….” The “I don’t knows” are deliberate and attorneys need to take their interrogations up one or two levels on the hierarchy of claims review.

Over the last several years I’ve noticed a “dumbing down” of claims handlers who somehow have either lost or never had the ability to speak or act in a manner consistent with those who have higher educations. Written communications are often disorganized and misspelled; there is no organized thought to the communication; and on occasion communications contain threats, and sarcastic comments typical of those with base level educations. Although claims handlers may be the lowest rung of claim review, they still represent the insurance company and should project professional customer service. Once in a while I come across claims handlers who are  just plain mean. A nasty and mean claims handler, stressed out by having to deny claims, is any insured’s worst nightmare.

Insureds and claimants should always keep in mind claims handlers are not the do-all or end-all when it comes to any disability claim. Claims handlers will tell you anything to get you to do what he/she wants. Recently, one of my newer clients told me the claims handler told her to submit a blank Attending Physician’s Statement each month if she didn’t have a doctor to fill out the form.  What? Of course, when another claims handler was assigned the claim, the situation changed drastically and the claim was nearly denied.

Other callers informed DCS their handlers told them, “not to worry about it.”  Whenever an insurance claims handler says, “there’s nothing to worry about”, start “worrying about it” and pay attention to the issue at hand. Sometimes claims handlers are so stressed out they will say anything on the phone to make the problem go away. (Another reason for not communicating with insurers on the phone!)

Bottom line, claims handlers:

1. Do not make independent claims decisions and must obtain “validation” from a higher up for nearly everything they do. (Often depends on their level of experience and title.)
2. Are not contract specialists and cannot answer questions concerning contract policies on any credible level. This is part of the “dumbing down” of claims staff.
3. Do not have access to financial reserve information as a safeguard for plausible deniability to regulators that claims handlers aren’t targeting claims.
4. May not communicate with you in a professional or college-level manner.
5. Are performance managed as to how well they can “push” disability claims through internal processes to obtain documentation to deny claims and how well they obey internal protocols without resistance.
6. Insurance claims handlers are constantly looking over their shoulders and protecting their backsides with peers and managers.
7. Are micromanaged on a daily basis to ensure backlogs are resolved and the chain of denials are kept constant.
8. Are subjected to daily propaganda through emails, unit and departmental meetings continuously communicating messages the insurance company is doing the right thing. Some insurers put forth messages convincing claims handlers all insureds and claimants are malingerers and have filed claims for secondary gain. Insureds become “the bad guy” from the time a claim is submitted.
9. Claims handlers do not document phone conversations accurately, but listen with a prejudiced ear for key phrases and information favorable only to the insurance company. Phone calls to insureds are always made with a deliberate agenda to obtain information supporting denials.
10. Claims handlers may not tell the truth.

There are certain parts of the claims process insureds and claimants need to put into perspective and understanding the role of claims handlers is the most important of these. Insurance claims handlers, despite their often showy delusions of grandeur, are exceptionally paid paper pushers with little to no authority to make any real claims decisions. If you are still speaking directly with a claims handler (which we do not recommend) exercise due diligence and judgement.

 

 

 

A Hard Lesson About Attorney Fees by Linda Nee

Most attorneys who read Lindanee’s Blog detest posts criticizing fee structures and future fee agreements and refer to my recommendations as “so much chortle.” 

Therefore, let me say coming out the gate that there are several attorneys I am aware of who charge reasonably and fairly for their work litigating and assisting  disability insureds.  DCS, Inc. maintains a list of  such attorneys and makes all appropriate referrals to them when necessary.

However, DCS, Inc. received a call from a Unum and Mutual of Omaha claimant who communicated to me her story of having two claims on appeal with a prominent attorney in New York. Unfortunately, it was a recount of experiences I’ve heard many times expressing dissatisfaction with attorney fees after having received nearly nothing for the money paid.

Apparently, this insured agreed to a 33% future benefit attorney fee (net benefit of $4,000) to age 65 to overturn an ERISA appeal with Unum. This appeal was successful for only 24 months since Unum took advantage of the 24 month limitation of benefits for mental and nervous conditions and closed the claim. An appeal was made for benefits beyond 24 months, but was lost. In the meantime, the same insured’s claim with Mutual of Omaha was also denied and   her attorney lost the appeal.

With two lost appeals, and no benefits the insured received yet another bill from her attorney for $11,000 bringing the total fees paid for legal services to a whopping $55,000! Currently, her attorney is “reviewing the ERISA record” to determine if litigation would be worthwhile and additional fees will be forthcoming.

When I spoke with this insured she was completely frustrated, discouraged, out of funds, and angry with her attorney. “He didn’t do anything to support my appeals, Linda”, she told me. ”No vocational report, no additional records, nothing. I only spoke with him twice and his staff called a few times.”

I asked her if she had spoken to her attorney candidly about her dissatisfaction and she replied, “No, he’s always so aloof and doesn’t answer my questions. He never tells me anything and his staff always returns my calls. I don’t think he did very much to help, really.”

Given the number of calls DCS,Inc. receives regarding exorbitant attorney fees, allow me to make the following suggestions:

1. Do not be afraid to challenge an attorney when he/she isn’t doing anything for the claim. Attorneys often have the same “god complex” physicians have making it very difficult for clients to challenge what they do or don’t do. However, for $55,000 in fees, it is wise to remember the attorney works for you not the other way around. It’s ok to ask your attorney why writing several letters to the insurance company was worth $11,000 in fees. Demand to know how many actual hours were spent on your case, and pay special attention to his/her billing statements to make sure the work product equals the stated time spent. Attorneys aren’t gods and work for clients, not the other way around.
2. There are no $300 an hour paralegal phone calls. Paralegals and office staff shouldn’t be billed at the attorney per hour rate. If you are receiving calls from office staff only, make sure the billing statement isn’t billing you the attorney’s per hour rate for those calls.
3. Negotiate attorney fees. My experience in working for and with attorneys is that they are inclined to consider negotiable fees rather than lose a client. For ERISA claimants it might be a good idea to have the attorney put in writing that he will return any court awarded attorney fees to you if the case is won. Some attorneys do not return court awarded attorney fees to the client. It’s always a good idea to try to negotiate attorney fees and don’t allow them to intimidate you with their reputation.
4. Ask for a plan of action as to how the attorney will manage your appeal or claim and then hold him accountable for it. It has been my experience that some attorneys actually “do nothing” during the 180 appeal period so that he/she can charge future fees for litigation or get that 40% settlement fee on the courthouse steps. ERISA claims do not have great success rates in some circuits. Insureds should be really clear about expressing what they want their attorneys to do for them. If you want your claim overturned on appeal and paid, say so, and hold the attorney accountable for making it happen. 
5. Don’t put up with aloof. If your attorney fails to return calls or provide you with information requested, ask for an in-person meeting and discuss your dissatisfaction. Ask your attorney to improve his contact with you. If the situation does not improve, find another attorney and ask for a refund of future fees i.e.invalidating fee agreements for future benefits.
6. Last resort – write a letter to The Bar.  No one really wants to make trouble for an attorney, but in some cases it may be warranted. It’s always best to try to resolve issues first before filing a formal complaint.

Unfortunately, the above insured in now in a bad situation. “I want to hire another attorney, Linda, who do you know?” With $55,000 in fees, another invoice for $11,000 and two failed appeals, this claimant is worse off than she was. One has to wonder if she wouldn’t have been better off keeping the $66,000 and letting the claims go by the wayside, given her age approaching 60.

Those of us in the business know insurance companies are unpredictable and flaky at best; therefore fees should never be based on expected or predicted outcome which is usually illegal anyway. However, some attorneys are often part of the problem not the solution and deprive disabled persons of life savings and money needed for future security and health care with little real work given in return.

Unfortunately, some claimants and insureds learn hard lessons and the financial cost is overwhelming. I am always surprised to be contacted by those who are discouraged with the services received from attorneys. .

Not all attorneys take their clients to the cleaners. I am aware of counsel who are  dedicated to ERISA claimants and often take cases for minimal fees. While we applaud the few who try to help ERISA claimants and actually put in “non-billable” hours to win, there are many others who continue to charge “by reputation and court standing” and put in little real effort to help the claimant. It really is a shame.

Farewell to 2011 – A DCS, Inc. Look-Back

Although 2011 proved to be a difficult year economically for insureds DCS, Inc. reported successes and failures of disability insurers to pay claims fairly. Most insurers increased targeting of claims to increase profits not realized through portfolio investments which reduce the cost of claims. The consequences of aggressive risk management by all major U.S. insurers was hard-felt by most insureds with open disability claims.

As a company DCS, Inc. reports a 90% success rate overall for 2011. The growth of Lindanee’s Blog topped goals and expectations for the year recording 169,725 all time reads, 751 reads on our busiest day, and boasts 189 subscribers representing both blog and comment subscriptions.

DCS, Inc. made 27 referrals to attorneys who have reasonable fee structures and extensive success rates for disability litigation, particularly for ERISA claimants. Of these cases, attorneys either settled or won their litigation.

In 2011 DCS, Inc. averaged 25-30 calls and 20 emails per week from those seeking information and advice concerning the management of their disability claims. Although I was unable to return all of the calls received, many were referred to Lindanee’s Blog which as of today contains quite a bit of information useful to insureds and claimants.

DCS, Inc. is first and foremost a consulting fee-based business. Although we attempted to provide those who contacted us with useful information, readers should note there is a level of information, expertise and knowledge which is available only to DCS clients. A detailed description of how to become a DCS, Inc. client can be found in a tab located at the top of the Blog homepage.

One of my personal objectives for 2012 is to finally write a “how to” book called Disability Claims Boot Camp as well as additional educational articles and booklets relating to the disability claims review process.

The most frequently asked DCS questions in 2011 were those related to Social Security Disability Income (SSDI) repayments, dependent off sets, and whether or not insurers had the right to reduce benefits by awards made to dependents. Several very good articles dealing with these subjects were added to Lindanee’s Blog to address topics related to overpayments and repayments.

Information, situations, accounts, and details posted on Lindanee’s Blog are the direct result of personal accounts related to DCS from actual insureds and claimants, and/or actual documents provided to DCS, Inc. from insureds’ claim files and communications from insurers to our clients. Unless a post specifically states, “in my opinion” all other information is supported and backed by actual documents and personal accounts directly from insureds.

In 2011 a handful of employees and former employees from Unum came forth with valuable information helpful to Unum insureds. Although I do not publish the names of specific individuals on the Blog, Unum’s former employees are recognized for their courage and moral decisions to publicly state what is true. Thank you!

For 2012 I have added a category on the Blog entitled “Testimonials” which should be used only by DCS, Inc. clients. Clients should feel free to post specifically to this category on the blog, but only one post per client please.

I would like to personally thank all of our readers for their continued support in 2011. DCS, Inc. will continue Lindanee’s Blog in keeping with our mission and philosophy of helping insureds protect themselves from disability insurers who deny claims unfairly. Again, I appreciate all of our readers to the Blog and look forward to 2012.