This is a situation that far too many claimants find themselves in. You can appeal your claim yourself, or find a consultant who will assist you. However, what I’m recommending is that ERISA Plan participants who are not treated fairly should inform their employers (in writing) of what happened and ask that the company not renew its Plan with that company. Group insurers can’t stay in business if employers refuse to buy their Plans.
Unfortunately, nearly all of the US group insurers are equally bad these days. Unum, Prudential, CIGNA and MetLife are definitely out in terms of reviewing claims fairly. CIGNA just merged with Blue Cross/Blue Shield and if anyone has ever tried to get in touch with a health insurer on the phone, you will know what I mean about delayed holding on the phone – not a good sign.
But, if you feel your insurance company was unfair, I’d certainly let your employer know. Employers are not mind readers and need to be informed when insurers are unfair and deny claims without just cause. Maybe your employer should insist on a service contract?
What’s up with DMS? I’m getting far too many requests for information.
Disability Management Services is a reinsurance company and as such is interested only in “resolving” claims by denying or settling them. Reinsurance is a concept whereby insurance companies pay other insurance companies to assume all or part of their risk. The point is for DMS to either settle or deny claims and have quick turn overs for new business; that’s how they make their money.
In the last two weeks DCS, Inc. received 5 calls from insureds with claims managed by DMS, so we know something is going on there. My experiences with DMS haven’t always been that good. The company engages in over the top investigations that it twists and turns to fit its needs. Claims handlers aren’t professional or “nice”, but rather make insureds feel they have done something wrong. In my opinion, DMS seems to manage claims for the “quick buck” and isn’t really interested if insureds are really disabled or not.
I certainly will be keeping an eye on DMS, but for the moment the company’s reputation is heading south.
Can you explain what a medical restriction and limitation is? What’s the difference?
In theory, both medical restrictions and limitations should be connected to one’s occupation and written by a physician after he/she has reviewed the patient’s job description. In truth, most treating physicians never see a job description and either do not write R&Ls properly, or do not link them to the patient’s occupation.
By definition, a medical restriction is those work activities the patient may never do. For example, a restriction for the occupation of Administrative Assistant diagnosed with carpal tunnel might read, “Patient is permanently restricted from keyboarding.” This statement is clear, and says what it means – no keyboarding at all.
However, in the same example as above, a physician might write a work “limitation” defined as work activity the patient may do, but only to a limited extent such as, “Patient is limited in her keyboarding ability to no more than 15-20 minutes at a time intermittently.
It is extremely important for insureds and their physicians to understand R&Ls and their importance in establishing medical disability, particularly for private insurance. Unlike Worker’s Compensation that depends on the determination of a percentage of whole body disability, private insurance disability is determined by medical “restrictions and limitations”, and if absent or poorly written could result in the non-payment of claims.
I don’t understand why my insurance company just won’t leave me alone. I’ve been paid for nearly 12 years now and my insurer continues to harass me. What can I do?
All disability insurance companies have the right to conduct investigation of claims for as long as they are paying you. There is never a time when insureds enter a “payment safety zone” but can be asked to produce “proof of claim as often as is reasonably necessary”, or every 30-45-days. For Individual Disability insureds may be asked to produce “proof of claim” every 90 days if the insurer really wanted to.
In some respects, insureds and claimants are actually lucky that most insureds don’t ask for update information every 30 days but often extend the time to quarterly, or even yearly. Still, there is never going to be a time when insurers just accept your total disability and put you on a pay no mind list. Frequent requests for updates take place in the beginning and may taper off eventually, but they will never go away.
Once insureds understand the insurer’s rights to updated information, received requests won’t be so scary. I’ve received phone calls from insureds who tell me they went 12 months without an update request but described the request as “harassing.” This isn’t harassment.
Insurance companies are permitted to investigate claims as long as they have liability for them and the requests should be treated as normal and customary. Just fill out the paperwork and move on.