Feeds:
Posts
Comments

This past week I received a copy of a request sent to a claimant from Genex asking for an Authorization to release financial records. The problem was that I’d never heard of this particular claimant who is not, and never was a DCS client.

Although I’m quite sure Unum is well aware of what I do, there is no reason to be sending me copies of communications addressed to those with whom I have no association.

I called GENEX to inform them the copy they sent to me was a mistake. At first, the rep said they had no such file claim number. Later, she told me she didn’t know why I was copied on the letter. “So, you do have information concerning this client?”, I asked.

Ultimately she did say Genex was aware of the insured, but was still unclear why I had received her letter. It’s interesting to me that Genex’ letter states the following: “Genex is committed to protecting the confidentiality of any personal information you provide.” I guess we can all surmise how that works.

Apparently, Genex is back on Unum’s tool belt assisting with SSDI matters and applications. If a simple letter is sent to the wrong person, do you really want to entrust SSDI applications as well? I attempted to get in touch with the actual claimant, but I was unable to do so.

Please be advised that in my opinion Genex shouldn’t be trusted with medical records and other SSDI information. DCS, Inc. recommends local SSDI attorneys for assistance with applications for SSDI. If you wish I can explain the SSDI application process to you if you want to give me a call.

In the meantime, Genex is clearly not the way to go for the following reasons:

  • It has been reported that Genex does not always use attorneys to assist for SSDI and the process appears to be muddled and chaotic.
  • Genex either does not communicate, (in one incidence for over 9 years), or, the company makes so many calls it’s harassing.
  • Genex is the agent of Unum, and is not an advocate for you.
  • What Genex knows, Unum knows.
  • Genex’ potential lack of privacy in sharing information, or potentially losing information, and losing control of where your information actually is.

I will have more to say in the next post about privacy, but Genex is not a good bet for SSDI Advocacy and shouldn’t be used regardless of how it sells itself.

DCS, Inc. does not recommend any third-party SSDI advocates including Allsup and Advocator Group.

 

 

Friday Q & A

Is FMLA self-insured?

Actually, FMLA, which stands for the Family Medical Leave Act, is neither insured nor self-insured – it is a federal law.

FMLA is law that requires employers to hold your job and continue to pay your benefits (not wages) for a period of 12 weeks. Essentially, it is unpaid leave that runs consecutive to Short-Term Disability. Some employers voluntarily extend the 12 weeks as part of their total employee benefit plan, but at the end of the day, employers can terminate your employment anytime after the elapsed 12 weeks with the blessing of the federal government.

Employers are required to notify employees of the termination and offer COBRA to replace healthcare. This insurance is very expensive because “COBRA” really means that the employer continues to include the employee in their group health plan after termination but charges a 40% or more surcharge to do so.

In any event, FMLA is unpaid leave mandated by law and is not “insured” at all.

Are “indexed earnings” the same as a COLA?

No. In fact, these are two separate definitions in the disability Plan or policy. Notice that we have “indexed earnings” which has nothing to do with benefits. In short, “indexed earnings” calculations are only used to determine “gainful occupations” as part of the change in definition investigation, or in residual calculations for someone working part-time. The key word here is “earnings” which distinguishes it from added benefits.

A Cost of Living Allowance is an additional benefit mentioned in Plans and policies to compensate for inflation. ERISA Plans rarely include a COLA because the premium is more expensive to employers, but IDI policies often contain COLA provisions.

What is “regular care”?

Regular care means that insureds and claimants are required to consult, or see their treating physicians, as often as is reasonable for the claimed disability. For example, an insured diagnosed with cardiomyopathy may need to consult with his/her cardiologist a minimum of once per month while another insured with post laminectomy syndrome might see a physician every other month.

Insurers always review claims to determine if insureds are in “regular and appropriate care”, meaning they are consulting with physicians with appropriate specialties, in addition to seeing them on a regular basis.

Having a paid disability claim requires all claimants and insured to be under the regular care of qualified physicians. Dropping out of regular care is a legitimate cause for claim denial. If you have any questions regarding what is and isn’t regular care please give me a call.

 

 

MetLife’s reputation as an unfair disability insurer was well-earned today and the company’s representatives should be ashamed of themselves. I received a call from one of my insureds who was recently diagnosed with cervical cancer and recently came out of surgery in a great deal of pain.

She asked me, from the hospital, to contact MetLife and ask for an extension for sending in her forms which she had been working on prior to the new diagnosis and surgery. She was not able to speak to me for long and I could tell she was in a great deal of pain.

I contacted MetLife and began speaking to a Customer Service Representative. I tried calling earlier, but received a busy signal when I entered in the claims handler’s extension. This time around I opted for the Service Rep. who when I informed her that my client had been hospitalized and received surgery promptly said rudely, “So when is she going back to work?” With that, my response was, “Excuse me?”

One of the things I say the most on the blog is, “Disability insurers know nothing about disability”, and to be honest, as a consultant, I find myself often defending the rights of disabled insureds to be treated with respect and compassion. When I asked to speak with a supervisor I was told that “someone would get back to me”. In essence, the manager refused to handle the problem.

Later, I did receive a voice message from the original claims handler, but when I returned the call she didn’t pick up. The customer service rep was rude, continuously spoke over me, and just wanted to know “when she was going back to work.” Incidentally, this claimant has been on claim for about 10 years now for another impairment, so the issue of return to work wouldn’t have been relevant anyway.

Apparently, in order to get an extension for paperwork, I would have needed to tell the rep when my client’s next doctor’s appointment would be – yet another really dumb question for someone who just came out of surgery.

The only time I could get the rep to be quiet was to finally say to her, “Do you not care about Marcy?” (Not her real name.) There was a quick moment of silence before the rep again chatted incessantly over me about next appointments…when did she last see her doctor etc.

I would like to share with those of you managing your own claims that there should never be a time when your insurer should be allowed to treat you with disrespect and lack of compassion. In fact, for my clients, I defend these basic rights every time I come across claims handlers, who above all else, lack basic qualities of human compassion.

What would have been so wrong for MetLife’s rep to simply say, “I’m sorry, Ms. Nee, that your client is having such a hard time. I’ll make sure your request is documented and sent to the claims handler. She will probably get in touch with you about the extension. Thank you for letting us know.” Do they not think?

In any event, I consider MetLife’s handling of a simple notification of hospitalization and surgery to be an unconscionable disgrace.  Those who know me can probably guess what my next step will be.

However, please know that all insureds and claimants have the right to be treated with dignity and respect when you contact your insurers. As a claims consultant, I insist on that basic right every time.

 

 

Heading To Canada?

Most of us already know the devastating effects of trying to obtain health care under our current systems in the United States. Despite a growing disparity in the Healthcare Marketplace, the issue of health care has become a real political issue that half of the country isn’t happy with.

Here is an email I received. It portrays a sad situation, however, some US citizens are considering immigration OUT of the United States to Canada just to receive proper medical care. From what I’m hearing, other than medical care, Canada might not be a good choice to establish permanent residency considering other aspects of life.

“… I have traveled and am arranging to relocate full or part time to Canada and am looking at cities and immigration options. I had one doctor say I have kidney disease, overfunctioning, in 2013 and gross overfunctioning reverified by a test in the past year.

The good news is I thought diabetes would rule me out of immigration there but a doctor said they don’t rule out for diabetes per se (they invented insulin and it is affordable unlike the US)  but body organ damage specfic to kidneys and creatine test would keep me from immigrating, as well as possibly age. So I am checking. The good news is my creatinine test has generally been normal, close to abnormal or within normal ranges so I would not be automatically ruled out if it tests ok on the  normal tests. I hope US and Canada have same standards. I did have higher readings last test just a little above normal but the nurse who read it  said it is considered normal enoughl. If I look to immigrate, I feel I need to do it now before that body organ damage occurs and keeps me here forever.

They were so nice and helpful. I feel safer. I had hypos and they helped, got direction, helped me get a gratis lancet device, retail humalog 325 or 350 usd here and about 25 usd there. I was sick a bit of trip and stayed in recovering from gross glucose and they were so helpful. Dropped an insulin vial when I went low and they found it and remembered me and got it back to me.  I was impaired and they were just nice and safe.

In the US I have been slapped by a first responder firefighter when I was low, separated from my glucose meter and insulin by police by their unawareness and luckily I was well enough to get it back, I was left to get no help not even 911 when I started to go into a hypo in a taco bell drive thru driveway where I live, too impaired to remember I had glucose, and I was run through the ringer with 4 cancer scares and then a  precancer scare the last 2 years luckily mostly clear except for the mass amount of radiation (in Canada there is medicine that reduces dna damage from ct scans by half, and not approved here btw), an awful and totally preventable hospitalization if I was properly diagnosed, and meeting catastrophic limits the last two years for all this insane care. “

Again, this is a sad situation, but for some people the only option.

First Lucens – Now GENEX

For the past year, a company called Lucens has been chasing Unum’s SSDI financial information in order to recalculate claims in hopes of finding nickels and dimes of unpaid overpayments.

Well, it looks as though Lucens didn’t last all that long, at least on Unum’s SSDI requests. Claimants are now reporting requests to obtain claimant SSDI financial data  are from GENEX, Unum’s old on-again, off-again SSDI partner. It’s unclear whether Lucens is sticking around to deal with Unum’s settlements, I seem to think they might be.

DCS, Inc. has received several calls this week from claimants confused with the request to sign an SSDI Authorization from GENEX with a supposedly Lucens created form. Claimants are themselves questioning where the Authorizations are coming from even though the form is deceptively designed to look like an SSA-form.

Actually, Unum’s claims process seems to be somewhere between, “I don’t know….let’s request it again…and let’s not read the files.”  Even though Unum Life Insurance engaged in unfair targeting, at least the former company supported “exceeds” customer service and strict organization of the claims process.

Unum group actually turns their claims employees into village idiots (sorry) and then sends them to Disneyland to “Aspire” to be great. Go figure! In reality though, Unum insureds and claimants seem to feel more confused and frustrated with the claims process than ever.

Today, it’s hard to work for Unum insureds and claimants when the Unum agenda includes claims handlers who have no idea what they are doing. It appears as though the administrative personnel are just pushing around paper which doesn’t do much to help Unum’s claim back logs.

How many of you have received recent letters from Unum requesting nothing, but simply informing you, and apparently it, that both parties have the right to request an IME? Or, letters from Lucens – no wait – GENEX, asking for SSDI financial records? Or, a questionnaire that seems to come out of the blue? Finally, a “second request notice” for information you faxed yesterday.

In my opinion, Unum lost control of the claims process and it shows. What’s next? In any event, GENEX is now the company who is sending out SSDI Authorization requests and my recommendations remain the same. (Please see prior posts.)

Are you finding it irritating that your Unum claims handlers keep asking for the same information over and over again? You just sent in your SSDI approval letter and once again your claims rep is asking for it again? What’s going on? How many times should you be expected to send in the same information over and over again?

Unfortunately, your Unum rep is not reading your file and probably doesn’t know what’s in it! Or, Unum is so paranoid about their Lucens SSDI initiative that management is forcing the U-numbies to request it again. Either way, it becomes damned irritating to have to fax the same information today you just faxed yesterday!

Unum doesn’t have paper files anymore but uploads everything electronically that is readable by claims handlers on their screens. To be honest, this process drove me crazy and crosses your eyes after a while looking at one, and maybe two lit computer screens at the same time. It doesn’t surprise me at all that Unum’s bottom administrative reviewers are avoiding reading the files.

Why Unum management doesn’t take more of a role in making sure its claims handlers read the files is surprising. Requesting the same information over and over again isn’t cost-effective for the company and is extremely irritating to insureds and claimants. At least at Unum Life Insurance we were expected to read the files and be familiar with claims enough to know what’s in them.

My suggestion to insureds who are asked to submit the same paperwork over and over again is to send a fax reminding the claims handler that you have a confirmation of fax receipt that it was previously sent. You can politely say, “May I suggest that you check the file?” You shouldn’t just rush to fax the information again until such time as the claims handler has had an opportunity TO READ THE FILE.

Unum claims handlers are quickly becoming the new negligent, uninformed group of the insurance world. Whatever happened to the expectation that claims handlers should KNOW the file before trying to manage it?

 

 

 

 

 

As most of you should know the proposed ERISA changes intended to go into effect on January 1st were extended to April 1, 2018. The extension was caused by the insurance industry’s opposition to changes that would “cost them more money”, or “cause the elimination of disability insurance offerings.”

Of course we can all assume that the real reason for the opposition is that the proposed ERISA changes provide an even playing field for claimants and make it more difficult for insurers such as Unum, (a company opposing changes) to deny appeals.

Lately, DCS Inc. has been receiving calls from claimants telling me that attorneys, who formerly refused to accept their cases, are calling them marketing their services under the proposed new regulations. I also heard from several sources that some attorneys are putting forth the changes when they aren’t even effective yet.

Wait a minute Esq.’s! The ERISA changes won’t be effective until April 1, 2018, if in fact they are approved. Try as I might to find ways to be kind to attorneys on the blog, I think over booking the ERISA changes prematurely, or marketing future services based on the proposed changes sounds a bit like a squeaky wheel to  me.

In any event, please see the proposed changes listed below. If these changes do go through the Department of Labor claimants may finally get an even playing field in the ERISA claims review process.

Disclosure Requirements.Benefit denial notices must contain a more complete discussion of why the plan denied a claim and the standards it used in making the decision. For example, notices must include a discussion of the basis for disagreeing with a disability determination made by the Social Security Administration (“SSA”) if presented by the claimant in support of his or her claim. (Actually, Unum already does this and has a scheme in place to “not consider” SSDI decisions.)

Claim File and Internal Protocols. Benefit denial notices must include a statement that the claimant is entitled to receive, upon request, the entire claim file and other relevant documents. Currently, this statement is required only in notices denying benefits on appeal. Benefit denial notices also must include the internal rules, guidelines, protocols, standards, or other similar criteria of the plan that were used in denying a claim, or a statement that none were used. (Internal claims manuals etc. would need to be provided.) Currently, denial notices are not required to include these internal rules, guidelines, protocols, or standards; instead denial notices may include a statement that such rules, guidelines, protocols, or standards were used in denying the claim and that a copy will be provided to the claimant upon request. (Insurers may decide to republish their benefit claims manuals to remove process disclosure. Some companies such as Lincoln Financial and Liberty Mutual will have a problem with giving up this information.)

Review and Respond to New Information. Plans may not deny benefits on appeal based on new or additional evidence or rationales that were not included when the benefit was denied at the claims stage, unless the claimant is given notice and a fair opportunity to respond. (This suggests that appeal denial decisions must be based on whether or not the original denial was the right decision to make. Many insurers engage in ad hoc investigations to obtain new evidence to deny claims.)

Conflicts of InterestPlans must ensure that disability benefit claims and appeals are adjudicated in a manner designed to ensure the independence and impartiality of the persons involved in making the decision. For example, a claims adjudicator or medical or vocational expert could not be hired, promoted, terminated, or compensated based on the likelihood of the person denying benefit claims.

Deemed Exhaustion. If a plan does not adhere to all claims processing rules, the claimant is deemed to have exhausted the administrative remedies available under the plan, unless the violation was the result of a minor error and other conditions are met. If the claimant is deemed to have exhausted the administrative remedies available under the plan, the claim or appeal is deemed denied on review without the exercise of discretion by a fiduciary and the claimant may immediately pursue his or her claim in court. A plan also must treat a claim as re-filed on appeal upon the plan’s receipt of a court’s decision rejecting the claimant’s request for review.

Coverage Rescissions. Rescissions of coverage, including retroactive terminations due to alleged misrepresentation of fact (e.g., errors in the application for coverage) must be treated as adverse benefit determinations, thereby triggering the plan’s appeals procedures. Rescissions for non-payment of premiums are not covered by this provision.

Communication Requirements in Non-English LanguagesBenefit denial notices have to be provided in a non-English language in certain situations, using essentially the standard applicable to group health benefit notices under the Affordable Care Act (“ACA”). Specifically, if a disability claimant’s address is in a county where 10 percent or more of the population is literate only in the same non-English language, benefit denial notices must include a prominent statement in the relevant non-English language about the availability of language services. In such cases, plans also would be required to provide oral language services in the relevant non-English language and provide written notices in the non-English language upon request.

Claimants should be aware that these proposed changes, if approved, won’t be effective until April 1, 2018. In my opinion it is unethical for attorneys to be marketing their services based on changes that are not yet approved or in force. If you receive any cold calls from attorneys on this matter, tell them to take a hike, at least until April 1st.

%d bloggers like this: