One of the questions DCS continually receives from insureds has to do with Unum’s management of Depression claims. This is an area in which Unum has been severely criticized particularly the State of California which found multiple abuses in this area during its conduct market evaluation back in 2005. DCS hasn’t written on the subject, even though there is strong claims evidence the company continues to abuse the 24-month mental and nervous limitation in group policies. Unum’s treatment of mental and nervous claims differs as to whether the claimant has an employer-sponsored group policy (ERISA), or is covered under a regular disability income policy.
Claimants who are covered under an employer’s group plan have a 24-month benefit limitation for depression, anxiety and most psychiatric conditions listed on the DSM-IV. Those claimants who are legitimately diagnosed with a mental or nervous condition (and no other physical condition) will receive benefits for a closed period of 24-months after which the claimant is expected to have recovered and return to work. If the claimant is diagnosed with a more serious mental condition i.e. Bipolar disorder, the claimant has 24 months to apply for social security disability which hopefully will be awarded prior to the discontinuation of benefits at 24 months.
Unum actually has a very good pay system in place identifying M&N claims and automatically limits benefits at the end of the 24 months. If the insured is disabled due to a mental condition only, the claim is legitimately paid only to the 24 months, presuming a policy provision is in the policy limiting benefits. Unum refers to these denials as “uncontrollable” because the company doesn’t have to do anything to “make the denial happen.” When the 24 months expire, benefits cease.
Unum’s abusive tactics, however, involve those claim situations when there is both a physical and mental impairment contributing to the insured’s disability. The most popular opportunity for Unum to impose abusive practices is for fibromyalgia claims which is medically accepted as a two-pronged impairment consisting of both physical and mental symptoms. It is very easy for Unum (and other insurers) to claim the insured is really disabled because of his/her depression and NOT from non-existent physical symptoms that “go away with exercise.” For certain impairments it is very important for the insured’s physician to distinguish between “primary and secondary diagnoses” to insure benefits continue beyond the 24 month limitation.
As always, Unum seems to capitalize on every loophole and profit opportunity it can. Mental and nervous limitations open up new opportunities for strategies specifically designed to terminate more claims for profit at the expense of the insured. While I was still employed by Unum in the Psyche/Cardiac Unit, management at one point made an announcement to claims specialists that they were to target psychiatric causes of disability in an effort to pay for only 24 months. This was really a very nasty, nasty, strategy because it deliberately discounted legitimate physical disability when there was mention in the insured’s records of “counseling for depression” or any other mental health treatment. Let me give you can example.
Cardiac patients who have open heart surgery frequently are recommended for some sort of depression counseling as part of their recovery. It’s considered normal for CABG (coronary artery bypass graft) and heart transplant patients to be depressed for a period of time. In fact, it is more normal than not for MI (heart attack) insureds to request mental health counseling to assist with the PTSD and trauma of a near death experience.
It therefore became Unum’s pattern of practice to walk the claim in for a medical review with its internal Cardiologist who documented the recovery for a CABG was 4 weeks. If the insured was also receiving counseling beyond 4 weeks, then the primary cause of disability must be mental and nervous and therefore benefits were denied after 24 months. This Unum practice can get really crazy because Unum’s internal physicians can determine ANY physical impairment is really caused by a mental illness thereby limiting benefits. This consultant has personally witnessed Unum claim “somatoform” or “conversion disorder (it’s all in your head) just to pay claims for shorter time periods. Often, late stage Lyme is also claimed by Unum to be due to mental illness rather than the physical manifestation of symptoms leading to disability.
As you may conclude these actions are extremely profitable to Unum since there is a great deal of profit potential in paying a claim for 24 months instead of to age 65 or lifetime benefits. When successfully done on a large-scale, millions of dollars in profit can be realized. It’s not unusual then for Unum to require the cardiac insured to submit to a neuropsychological evaluation in an effort to document and prove mental instability. For extremely wealthy claims Unum will pull out its big guns and also have the insured interviewed by an IME Forensic Psychiatrist who will document the disability as some sort of mental disorder in order to pay for 24 months.
Unum does NOT accept the diagnosis of depression as a cause for permanent or long-term disability and will take every necessary action it can to prove that philosophy. Insureds must also show a Global Assessment of Functioning of 50 or less and a full AXIS I-IV evaluation in order to be paid benefits at all.
Fortunately for Unum, the game it plays with insured’s benefits often results in playing the numbers. If the “risk” of getting caught is less than the potential profitability, then hey, why not? For the insured, Unum also breaks its “good faith and fair dealing” duties by ignoring the co-morbidity of the totality of symptoms and concentrates only on one diagnosis at its discretion. “Self-reported and subjective” claims are a topic for a different post although also related to abuses of review in an effort to pay for a shorter time period. I’m sure the reader can see the potential of Unum claiming nearly every impairment is “self-reported” or “subjective” – and it does, if it can do so credibly.
In general, Unum’s medical department also has an internal strategy for depression claims which often shortens benefits to 12-18 months. Internal medical reviews I’ve read tend to indicate Unum may accept and pay depression claims for approximately 12 months. After that, the company engages in aggressive risk management to find out why with proper medication and counseling the insured is NOT better or able to return to work.
Doc-to-doc calls are initiated, psychological and forensic IMEs are requested in an effort to find out why the “depressed” insured isn’t able to return to work. Although these aggressive activities are initiated for both ERISA and non-ERISA policies, those WITHOUT 24-month benefit limitations will receive the lion’s share of harassment because of the potential of paying the “depression” claim to age 65 and even lifetime.
Often, with Unum’s internal MD’s OK, depression claims are denied after only 12 months rather than 24. And, the unknowledgeable and unsuspecting lay person just presumes “Unum knows best”, which is very unfortunate indeed. The only depression claims paid long-term are for those diagnosed with more serious mental disorders requiring ECT treatments or to those who are in-patients in a mental health facility. On occasion, Unum may also pay well-supported OCD and PTSD claims, but again after 12 months the company begins to look for an out to future payments.
Of late Unum has also been conducting surveillance on depression insureds which often leads to ridiculous claim denials because the insured is “suspected of dating” or “having sex.” While it is impossible to capture mental illness on a CD, Unum does try hard nonetheless to render unsubstantiated conclusions from activities which are more often than not part of the mental treatment plan. Any insurance company can interpret illness and impairment anyway they want to as long as it is documented by a physician with good credentials.
The lesson in this is that insureds and claimants should NEVER presume Unum is acting in your best interest especially those with depression claims. If there is a loophole, anywhere, Unum will capitalize on it and obtain documentation which makes it’s opinions and conclusions appear credible. Again, depression claims open up the door of opportunity for Unum to make a great deal of money and insureds with depression claims need to be “watchmen” and push back when appropriate.