Here’s Another Story: I live in California and my Employer was Un-Insured for Workers Comp. Insurance. As Yet, my 10 years of battling with MES Solutions and there Retired or No Office based Physicians who repeatedly have lied, mis-intrepreted my Treating Physicians Reports, Medical History, Labs, CT Scans, MRI’S and X-Rays from the very beginning, has fell on deaf ears from the WCAB. Wasn’t the WCAB formed to protect the Injured Workers? Why does’nt the State of California go after these Un-Insured Employers, their Attorneys and MES Solutions for perjury, fraud and medical malpractice? If MES Solution was sued for the Gross Neglient- Medical MalPractice Reports and Employer/Insurance biased Reports by ALL the states they practice in, it would be a Huge boost to our economy and assist those of us Injured Workers in getting much needed Good, Quality treatment/care from our Treating Physicians. |
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There’s been quite a bit of interest in these “outsourced’ peer review agencies and the harm they cause with bad reports rendered to disability insurers. A report was forwarded to DCS, Inc. done for The Harford by this physician: Dr. Ibrahim Alghafeer, M.D. Dr. Alghafeer completely discounted a fibromyalgia claim on which The Hartford based a file denial. |
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Posted in Claims Review Abuses | Leave a Comment »
Perhaps the worst disability fear for insureds is expecting a disability payment on the same day each month and not receiving it.
I know this fear because while I was still employed with Unum in 1999 and 2001 I had to go out on STD for two 30 day periods. Unum denied my STD claim both times; we can safely say Unum is an equal opportunity rainmaker. I actually chose to return to work prematurely just to rid myself of the absolute fear of not being able to pay my bills. The fear is real and its terrorizing.
Over the years my clients have experienced and reported to me many levels of fear when checks do not arrive on time. I’d like to discuss these situations by giving you more information to help you try to ”re-adjust your expectations.”
The more information you have about the system, the less fear you will have when checks do not arrive on time. Please note, I didn’t say the fear of NOT getting a check on time will go away entirely, but perhaps you won’t be quite so panicked.
First of all, most disability insurers release checks five (5) days in advance of when due so that the check will arrive on the date due. Some companies use 5 days, some 2 or 3, but the normal and customary procedure is to release the check in advance. The primary reason why checks do not arrive on time, is because the claims handler “forgot” to release the check in advance and it is going to be late. Some claims specialists manage the payment of claims better than others, but the primary reason why a check is late is because the claims handler, well………..made a mistake.
Generally, unless a claims specialist or representative has informed you in advance the company plans to deny your claim there is no reason to “assume” the insurance company has denied the claim. Not receiving a check in the mail, or in the bank when it is expected is like a “firebell in the night” to most insureds and the very worst is expected.
DCS, Inc. had a very sad situation this past Christmas when a client called Unum to find out where his check was two days before Christmas and was told the claim had been denied way back in October. The Unum claims handler really messed up on this one and it was very hard for this insured to get through the holidays. In fact, based on our claims experience, the only time when this DOES happen is when Unum is the insurer. All the other companies seem to manage cutting checks around the holidays very well.
Most disability insurers have a policy of waiting 10 days when checks sent in the mail appear to be lost. Checks can be voided and reissued, but only after the 10 day waiting period. This problem can be easily solved by setting up direct deposit. Some claims specialists do not tell you the truth about when the check was actually released.
Most of the time when DCS, Inc. is contacted about a “late check”, it later turns out it was an administrative error (a nice way to say the claims handler made a mistake) and the check is received a few days later. Disability checks can be as much as a week early or late around national holidays because of the post office or closing of banks.
So what should an insured do with the overwhelming fear, stomach butterflies, depression, palpitations, and anxiety when the disability check hasn’t arrived on time? This situation is the ultimate train wreck for insureds, and every day the check is late, the claim denial paranoia gets worse.
Remember, that 99% of the time disability checks are late because of an administrative error in releasing them on time. That’s all. Unless you have been notified in advance of a claim denial, chances are there is no reason claims should be denied, and certainly you will be notified in advance.
If you have someone helping you with your claim ask that they contact the claims handler and let them know the check is late. The only way to calm this type of fear is to contact the claims specialist and demand to know when you can expect the check. What you DO NOT want to do is sit at home crying and worrying. Once you know when the check was actually released the panic goes away.
In the beginning of a claim it sometimes happens the insured has a misunderstanding of when he/she is due to receive a benefit. Remember DI benefits are always paid in arrears. If your elimination period is 90 days you are due a benefit beginning on the 91st day. For example, let’s say you begin to be eligible for a benefit on January 15th. This means your benefit period will run from the 15th of January to the 15th of February. Your first check will be released around the 10th of March for the period Jan 15-Feb 15.
Granted, there may be other reasons why the insurance company “withholds” disability checks such as overdue medical updates, APS or Claimant Statements. If you’ve worked with DCS, Inc. long enough, then you know we place medical update information a priority in the claims process. If the insurance company asks you to update medical information, you really need to take care of that. ERISA claims can actually be denied for failure to provide medical information when requested for more than 30 days.
Still….not getting a disability check is scary and it’s the NOT knowing that will drive most insured’s crazy. Pick up the phone and call the claims handler and demand to know when you can expect your check. Once you know, the check has been released you’ll feel better. This is one situation you, the insured can do something about, thank goodness!
Choosing not to let an insurance company scare you regardless of the reason is key to your recovery as a disabled person. Stay in control of the process and let go of that fear of an “empty mailbox.”
Posted in Living With a Disability Claim | Leave a Comment »
Favorable Operating Trends and Solid Capital Position MaintainedCHATTANOOGA, Tenn., Feb 02, 2010 (BUSINESS WIRE) — Unum Group (NYSE: UNM) today reported net income of $199.4 million ($0.60 per diluted common share) for the fourth quarter of 2009, compared to net income of $41.8 million ($0.13 per diluted common share) for the fourth quarter of 2008. Included in the results for the fourth quarter of 2009 are net realized after-tax investment losses of $18.9 million ($0.06 per diluted common share), compared to $167.6 million ($0.50 per diluted common share) in the fourth quarter of 2008. Net realized after-tax investment losses for the fourth quarter of 2009 include an after-tax gain of $22.7 million resulting from changes in the fair value of an embedded derivative in a modified coinsurance contract, compared to an after-tax loss of $120.1 million in the fourth quarter of 2008. Also included in net realized after-tax investment losses for the fourth quarter of 2009 is a net realized after-tax investment loss of $41.6 million related to sales and write-downs of investments, compared to $47.5 million in the fourth quarter of 2008. Adjusting for these items, income on an after-tax basis was $218.3 million ($0.66 per diluted common share) in the fourth quarter of 2009, compared to $209.4 million ($0.63 per diluted common share) in the fourth quarter of 2008. “The Company had another solid quarter and we closed the year well positioned for the year ahead,” said Thomas R. Watjen, president and chief executive officer. “While we believe that the general business and economic environment will continue to pose challenges, the actions we have taken the past several years have positioned us well and provide us with significant operating and financial flexibility.” Insureds need to remember Unum’s big year-end push to deny claims and what that means. If the company can deny sufficient claims to produce profitable income for the year or quarter, it matters not that the same claims are litigated and paid anyway 6 months to a year later. Readers need to take a moment and really think about this. Terminated claims produce reserve gains in the period in which the denial takes place. If the claim is later litigated and re-opened the reserve loss is balanced against reserve gains for the period. In other words, thousands of disability claims were denied “in a hurry” by year end to produce 4th quarter and year end results. Many of these insureds will retain attorneys, litigate and settlements will be made on the courthouse steps. Unum doesn’t care since enough claims were denied to produce the results it was looking for in the time period needed. This kind of philosophy goes to hell, though, when claims are awarded bad faith punitive damages in addition to just paying the claim or settling. Unum may find “the cost” of targeting claim denials for year end is too costly when the punitive damages start rolling in. Remember, when disability insurers such as Unum claim increased earnings, it is denying more claims than ever. |
Posted in In the News | Leave a Comment »
One deer tick bite can lead to multiple infections
By Time for Lyme
(Article contributed by a successful Prudential client on appeal. Thank you.)
Columbia study reveals scope, likelihood of tick-borne illnesses occurring
As many as 70 percent of deer ticks are capable of passing on conditions like Lyme disease and recurring fevers to the humans they bite, says a recent study conducted at the Columbia University Center for Infection and Immunity.
Published in the September issue of the peer-reviewed Vector-Borne and Zoonotic Diseases, the study describes deer ticks as carriers of a “plethora of pathogens” potentially dangerous to humans. The most common disease-producing bacterium found in the roughly 300 New York deer ticks examined was Borrelia burgdorferi-the infectious organism that causes Lyme disease.
Researchers additionally found some deer ticks (2%) to be carriers of the Powassan virus, which can lead to a severe central nervous infection, along with life-threatening brain swelling and inflammation caused by encephalitis.
Symptoms of Lyme disease can range from fever, chills and body aches to joint swelling, weakness, severe fatigue, trouble concentrating and temporary paralysis. Many-though not all-people infected will see a bull’s-eye rash between three and 30 days after infection.
Although Lyme disease is most common in the Northeast, it’s been found in all 50 states. Those who live, or spend time, in grassy or wooded areas are most at risk. According to the Centers for Disease Control (CDC), more than 20,000 cases of Lyme disease are reported each year. Yet because most doctors do not report new cases of Lyme disease to the CDC, the actual number of new Lyme disease cases each year has been estimated to be as high as 200,000, says Connecticut-based neurologist Harriet Kotsoris, M.D., medical director of Time for Lyme-a non-profit organization working to eliminate tick-borne diseases through research, education and both state and national legislation.
“Couple the study results with these statistics, and it’s no wonder the CDC has classified Lyme disease as a health epidemic,” Dr. Kotsoris continues, adding that since 1991 the number of those infected with Lyme disease has doubled.
Because deer ticks can carry multiple disease-producing bacteria and microorganisms, it’s also possible for a human to develop two or more infections from one bite, researchers say. The Columbia study found that in addition to the bacteria that leads to Lyme disease, it is common for deer ticks (scientifically known as Ixodes scapularis ticks) also to carry:
· Babesia microti-a parasite that can infect red blood cells. Some people with the infection never experience any symptoms. In others, the flu-like symptoms can be life threatening.
· Anaplasma phagocytophilum-bacteria that can lead to an infectious disease called anaplasmosis. Treated with antibiotics, symptoms are flu-like and generally range from mild to moderate.
· Also found in a small percentage of ticks (2%) was Borrelia miyamotoi, a bacterium that is similar to the Borrelia lonestari, but has not yet been proven to cause disease in humans.
This study was made possible by a grant funded in part by Time for Lyme and the Columbia Lyme Center to support a fellowship to the lead investigator, microbiologist and Columbia postdoctoral research scientist Rafal Tokarz, Ph.D., an expert on tick-borne illnesses in humans.
“The results corroborate what many have feared-that more ticks are carrying more pathogens, and that without physician and public education, we could have a skyrocketing health crisis on our hands,” Dr. Kotsoris adds.
Congress is currently considering legislation that would mandate the U.S. Department of Health and Human Services to create a Tick-Borne Diseases Advisory Committee to coordinate efforts and improve communication between the federal government, medical experts, physicians and the public.
About Time for Lyme
Time for Lyme is an organization dedicated to eliminating the devastating effects of Lyme disease and other tick-borne illness. Its mission is to prevent the spread of disease, develop definitive diagnostic tools and effective treatments, and to ultimately find a cure for tick-borne illness by supporting research, education, and the acquisition and dissemination of information. In addition, TFL continues to act as an advocate for Lyme disease sufferers and their families through support of legislative reform on the federal, state and local levels.
Posted in Medical Information | Leave a Comment »
DCS, Inc. was notified by an insured that Lincoln utilizes the services of an independent review agency called AMR (Advanced Medical Reviews referred to as the AMR Peer Review Network).
According to its website, AMR conducts independent medical and peer reviews exclusively for insurance and worker’s compensation “utilizing innovative techniques” and providing “cost saving techniques to insurance companies.” http://www.admere.com/
The peer report I read solidified our opinion AMR is an insurance-paid defense agency that writes or “rubber stamps” denial decisions for insurance companies. These reports are then used to support legitimate claim denials which look credible.
For this particular claimant, AMR was used in the capacity of a medical review agency to “clarify medical restrictions and limitations” for the any occupation investigation or change in defintion of disability. AMR went directly to the claimant’s physician for a “buy-in” of its opinions. Luckily, the primary care physician in this case is ripping mad.
In addition, the AMR physician openly criticized the claiman’ts primary care physician and his longstanding treatment of the claimant. All this from an unknown physician who has no treatment history with the insured. Unbelievable!
Of course, the determination by AMR was that the claimant had “sedentary capacity”. Next, Lincoln will identify gainful occupations the claimant can do given that he has sedentary capacity for work (according to AMR).
The problem with these agencies is that we have no idea what the credentials are of those physicians who review the medical records of insureds. Clearly, AMR is NOT an independent medical review source since the company works exclusively for insurance companies to “save money” and apply “innovative techniques.”
Bottom line…..agencies such as AMR render opinions favorable to whomever writes their checks. You may notice AMR is also involved in reviewinig claims for worker’s compensation which is definately not the same type of review required for medical disability.
In this case, Lincoln got exactly what it paid for. Lincoln claimants and insureds take heed.
The AMR doctor signing this particular report is:
Dr. Jeffrey Bui, MD, California
License # A99664
The report was referred to as: Return to Work Potential
Posted in Reporting IME Physicians | 5 Comments »
It is very interesting to note that Northwestern Mutual appears to have dropped the ball into “claims handler chaos” lately. After changing claims handlers three times on one of our insureds, we still do not have a clue who is managing the claim. We were promised, however, a call back to identify yet another new claims specialist.
Usually, Northwestern Mutual provides excellent customer service; phones are are answered promptly, and issues are resolved with a great deal of professionalism. Unlike CIGNA, Prudential and Sun Life, Northwestern Mutual consistently manages its claims in a review process that makes sense.
Changing claims specialists frequently is an indication the company cannot retain qualified employees. Again, we’re looking for “patterns of business and claims practice” and not just one claims situation gone astray. It does seem unusual for NWM, an aristocrat among insurers, to fall into administrative chaos.
We’ll keep you posted.
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DCS, Inc. came across the STD policy pasted below written by the American Financial Group. The policy language is worth posting since it is one of the most restrictive STD policies I’ve come across to date. Policy contract language actually requires and uses “the objective evidence standard” to prove disability along with quite a few other restrictive eligibility requirements.
Also notice the policy excludes Physical Therapists and Pain Management providers from its “qualified” list. Contract benefits are self-insured which means American Financial Group funds the STD benefits, but may have a third-party administrator investigate the claim.
In reality, employees will probably not meet all of the conditions, be denied STD, and when FMLA expires, the employee will be terminated. One has to ask whether this policy provides employees with a benefit at all, but it is certainly one all employees should be cautious of and plan accordingly.
This policy is an excellent example of an occasion when employees should obtain a copy of their policies immediately upon enrollment and be aware of its contents.
HOW THE PLAN WORKS
Initial Disability
To qualify for short term disability benefits:
– you must be “Disabled” meaning you have a medical or psychological condition that is supported by Objective Medical Documentation (as defined below) and causes functional limitation(s) such that you are unable to perform the normal job duties of your regular job or any other job to which you could be assigned (with or without modification of those duties). The Objective Medical Documentation must support both the medical condition and any actual limitation(s) caused by the medical condition as determined by the Plan; and
– you must satisfy a five-day waiting period, determined on the basis of the number of days you work in your regular workweek.
The waiting period must be satisfied with paid time off to the maximum extent possible. Absences during the three-month period prior to the date of disability, documented by a Approved Provider as attributable to the disability, will be considered for the purpose of satisfying the waiting period. No partial days of absence during such three-month period will be credited toward satisfying the waiting period. The absences must have occurred after becoming eligible for Plan benefits.
Approved Providers
This term is defined to mean the following licensed persons who provide services within the scope of their license, and the full range of proper treatment for the Disability-causing condition that falls within the scope of the provider’s license and practice:
Physician – a doctor of medicine or osteopathy licensed to prescribe and administer all drugs and perform surgery
Nurse midwife/ practitioner
Dentist
Podiatrist
Ophthalmologist or optometrist
Chiropractor
Psychiatrist
Psychologist
Social worker
Physician assistant
Under Care by Approved Provider Required
Benefits will not be payable during any period of Disability in which you are not under the care of an Approved Provider. Your Approved Provider must document the Objective Medical Documentation that supports both the medical condition and any actual limitations(s) caused by the medical condition and timely submit this documentation to the Plan Administrator.
You must follow your Approved Provider’s recommended treatment plan. However, the treatment plan and length of Disability will be reviewed (including total Disability or partial Disability that may qualify for Rehabilitation Benefits) for payment of STD Benefits under the Plan based on current industry standards for your medical condition, illness or injury. A determination by the Plan Administrator that you are not eligible for continued STD Benefits under the Plan during a specific course of treatment does not mean that the recommended course of treatment should not be followed. Only you and your healthcare provider can decide what is the right health care decision for you. Decisions by the Plan Administrator or Claims Administrator are solely decisions with respect to Plan coverage and do not constitute health care recommendations or advice, see “Plan Determinations Are Not Health Care Advice” section below. In order to be eligible to receive STD Benefits under the Plan, your medical condition, injury or illness must also continue to satisfy the definition of Disability (as defined by the Plan).
Documenting A Disability/Objective Medical Documentation
You will be required to obtain statements from your Approved Provider during your disability. Failure to provide such statements, when requested, may result in cessation of your Plan benefits.
“Objective Medical Documentation” is written documentation of observable, measurable and reproducible findings from examination and supporting laboratory or diagnostic tests, assessment or diagnostic formulations, such as, but not limited to, x-ray reports, elevated blood pressure readings, lab test results, functionality assessments, psychological testing, etc. Such Documentation must be from the original dated medical record and support the claim of total Disability (or partial Disability requiring reduced hours, if appropriate). Objective Medical Documentation supports both the medical condition and any actual limitations(s) caused by the medical condition. Other examples of objective findings that may or may not support the presence of a disabling condition include temperature (or fever), lab test results, functionality assessments, psychological testing, etc. The Documentation must be legible and sufficient to allow another trained medical professional to review the case, and see how the original Provider came to his determination and decisions.
You may also provide “subjective” information as it relates to the Objective Medical Documentation. Subjective information is Documentation of non-observable or non-measurable symptoms. Subjective symptoms relate to how a person feels. Examples are: “My throat hurts,” or “I’m tired all the time,” or “I am in pain.”
Proper Care and Treatment
To receive STD Benefits, if you are eligible, you must:
Report the Disability, as explained in the “Claim Filing Procedure” section and stay in contact with the Plan Administrator.
Place yourself under an Approved Provider’s care and follow the recommended treatment of your Approved Provider as defined by the Plan Administrator (see “Approved Providers” above for the definition of an Approved Provider). Normally, you should seek treatment by an Approved Provider if your condition causes an absence lasting 4 or more days.
Furnish Objective Medical Documentation of your Disability to the Plan Administrator as soon as possible but no later than 21 days from your 1st day of absence, and cooperate with requests for additional information.
Report for medical or psychological examinations at the request of the Plan Administrator.
Obtain permission to travel from the Plan Administrator prior to traveling if you need to recuperate away from your home or leave your community for any reason at any time during your Disability.
The Participating Employer may also ask you, at the Participating Employer’s expense, to obtain a second opinion from a qualified medical provider and reserves the right to suspend your benefits until such opinion is received. In the event that the approved provider providing the second opinion does not validate that you are Disabled, Plan benefits will terminate on the date the opinion was received.
Posted in General Comments | 2 Comments »
DCS, Inc. continues to be amazed at the customer service turn around of the company. To date we don’t know if the insured’s appeal will be successful, but the appeals area has given the insured every consideration and opportunity to support a claim.
In addition, we’ve been kept informed of the status of the insured’s appeal at every step. We sincerely look forward to working with Aetna representatives when it’s clear they, and the company, are making an effort to review claims fairly. This is in direct contrast to Aetna’s former disorganized and unapproachable process.
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(I was actually an expert/consultant in this case and gave a deposition on the matter for Attorney Loughren and Phillips & Cohen. Unum forced all claimants to apply for SSDI benefits even when it was obvious the claimant intended to go back to work and was not totally and permanently disabled.)
Jury finds insurance giant Unum defrauded the U.S.
BOSTON, MA, Oct. 23, 2008 — A Boston jury has found that Unum (NYSE: UNM), the nation’s largest disability provider, defrauded the United States by forcing its customers to submit false claims for disability benefits to the Social Security Administration (SSA), when Unum knew that they were not eligible for government benefits.
By engaging in this fraudulent conduct, Unum imposed substantial burdens on an already overwhelmed Social Security program and caused the taxpayers of the United States to spend money to process and deny these false claims.
The jury reached its verdict late yesterday. The case was brought on behalf of the government by a whistleblower, Patrick Loughren, under the federal False Claims Act. Unum is based in Portland, Maine, and Chattanooga, Tennessee.
“Unum’s conduct in threatening people to apply for Social Security under penalty of losing a significant portion of their private disability benefits is wrong,” said Loughren. “After five years of intense litigation during which Unum refused to admit it was defrauding the United States, I am gratified that a Boston jury has called them to account.”
As part of its scheme, Unum compelled people seeking disability benefits from Unum to apply for Social Security disability benefits even though its customers often told Unum they were not eligible. Social Security has much stricter criteria for disability benefits than private insurers like Unum. In an attempt to enrich itself, Unum told thousands of claimants that it would cut their private disability benefits in half – or more – if they did not comply with Unum’s directive that they must apply for Social Security disability benefits.
Unum admitted during the trial that it had caused many of its customers to apply for Social Security disability over the ten years covered by this case. Unum had nearly 500,000 long-term disability claimants over this period. The full extent and magnitude of Unum’s conduct will be addressed in future hearings.
Before the trial started, the federal judge ordered that the case proceed in stages in light of the scope of the case. As a test case, the judge submitted five people’s disability benefits claims to the jury. After a four-week trial, the jury found that Unum had defrauded the United States with respect to two of those cases, was unable to decide a third, and found insufficient evidence with respect to two others.
By its verdict, the jury rejected Unum’s primary contention that it was entitled to force people to apply for Social Security disability benefits based on SSA’s open-door policy, which encourages individuals to apply for Social Security Disability benefits if they choose to do so. The jury found that Unum had violated the False Claims Act, confirming the Court’s earlier ruling that “an open door to claimants who are unsure they are eligible does not exonerate an insurer that knowingly causes ineligible insureds to apply.”
The jury also rejected Unum’s claim that it made people file frivolous Social Security claims because employers who bought group disability benefits from Unum wanted Unum to impose that requirement on their employees.
Loughren filed this “qui tam” (whistleblower) lawsuit in 2003. The False Claim Act allows private individuals to sue companies that are defrauding the government and to recover funds on the government’s behalf.
As a result of this lawsuit and a New York Times story that looked into this practice, Senator Charles Grassley (R-Iowa) sent a letter to Unum and eight other private disability insurers asking for detailed information about the very practices that have now been found to be unlawful.
Lead counsel for the whistleblower is Phillips & Cohen LLP, the largest and most successful law firm that specializes in representing whistleblowers in qui tam lawsuits. As a result of cases brought by Phillips & Cohen, the U.S. Treasury has recovered nearly $3 billion.
About the Firm : False Claims Act : Do You Have A Case? : Whistleblower Rewards & Stories : News & Settlements : State False Claims Laws : Contact
Posted in Claims Review Abuses | Leave a Comment »
DCS, Inc. Update February 2010 – 445 Reads/day
February 7, 2010 by lindanee
After 6 months on WordPress, Lindanee’s Blog receives on average 445 views/reads per day. We also received many emails from insureds and claimants telling us how important the information on the Blog is, and how it has helped to comfort and/or resolve questions.
Unum isn’t so happy to see our success though. We don’t mind Unum’s whining. In fact, if Unum began to investigate and evaluate claims fairly the company wouldn’t be such a huge topic on the Blog. Whether Lindanee’s Blog has Unum’s approval or not is not even on our priority list. DCS, Inc. is more concerned in providing insureds with the information they need to have successful claims.
We thank everyone who has subscribed to the Blog and hope you continued to stay tuned.
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