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Bad dudesDCS is receiving multiple calls and emails regarding Unum’s voluminous claim denials. Although most private insurers engage in “profiteering” tactics to some degree, I have not received any calls from insureds or claimants regarding sudden, unfair claim denials for 2016 from any other company.

Unum has been targeting and preparing claims for denial since the beginning of 3rd Qtr., and now within 3 weeks of year-end Unum has pulled out all of its bad faith practices to eliminate claims.

A good clue to Unum’s unfair “target-denial scheme” is the placement of Reservation of Rights status on claims just prior to profitability reporting periods. DCS is receiving more calls and inquires about ROR status and what it means to them.

In reality, ROR status is suspected of being connected to Unum’s BAS payment system. When coded, claim financial reserve is reduced thereby creating an immediate financial reserve gain and contribution to profitability.

Although Unum emphatically denies any connection between financial reserves and ROR status, the placement of increasing amounts of claims on ROR just prior to profitability reporting indicates the  opposite. If ROR is NOT connected to BAS, then why bother with Reservation of Rights at all?

Unum’s counter arguments about ROR are simply not believable as indicated by increasing numbers of claims placed on ROR status at this time of year. More and more calls are coming in about Unum’s ROR status at a time when no other insurer is doing so.

It’s important to understand that deliberately targeting legitimate, payable claims for denial can be referred to as racketeering, particularly when it wouldn’t be hard to prove Unum’s “patterns of practice” to sell disability policies and Plans it has no intention of paying.

Further, Unum’s persistent violation of the multi-state settlement agreement along with state departments of insurance who turn blind eyes toward the company’s unfair violations of insurance law further disclose an extremely corrupt insurance industry against those who are most vulnerable in our society – the disabled.

We should also not forget that Unum deliberately harms thousands of middle class families who depend on disability Plans provided to them by their employers. For some, employer-provided group STD/LTD is the only affordable coverage for disability available.

Although I’ve mentioned this in many blog posts, it is so important to avoid denials in the first place rather than have to appeal and retain attorneys who walk away with most of the money. While consultants are not always successful, listening to the experts who know is also extremely important.

Clearly, given the numbers of calls and emails I’ve received, Unum is harming many people who won’t be having Christmas this year.

surgical-patientOne of Unum’s most egregious claims practices is to telephone surgical patients shortly after they return from the operating room and ask about return to work.

Yesterday, I received a call from the spouse of an insured who was in the ICU less than 30 minutes when a call was received from a Unum claims handler asking about return to work.

Apparently, the insureds spouse had no idea who the call was from and picked it up. The claims handler demanded to speak to the insured who, as expected, could barely talk. Where do you begin commenting on something like this? How often do I have to say how unprofessional and deceptive Unum really is?

Unfortunately, this is not the first time I’ve encountered Unum’s post-surgical phone calls. Several years ago a DCS client had a CABG x 5 (coronary artery bypass graft in 5 arteries) and received a phone call from Unum also while he was still in the ICU. In this case, my client was having difficulty breathing and actually passed out during the call.

To begin, no one, and I mean no one, is obligated to take a call from any insurance company period regardless of when, where you are, or for what circumstances. None of Unum’s policies contain  “proof of claim” provisions requiring anyone to speak directly to claims reps on the phone. Even if Unum’s policies did contain such provisions, no patient in the ICU should take such calls.

The fact that Unum makes calls to post surgical patients is an indication of the company’s total disrespect for human life. There is no doubt but that Unum’s claims process de-humanizes the patient at a time when the patient is most vulnerable and in need of privacy to recover and heal.

Finally, I have to ask myself what kind of person (claims handler) agrees to make such calls in the first place? Are Unum’s claims handlers so frenzied with the bribe of a bonus in 2017 that they would stoop as low as to make calls to a hospital ICU?  Are you kidding me? This practice is totally unacceptable and Unum’s claims handlers know it.

Unum’s practice of  telephoning ICU patients who are just out of surgery is the most unacceptable claims practice there is. Family of insureds should always leave word with the nurses that no calls are to be received from any insurance company while the patient is recovering in the hospital.

Further, Unum’s haste to deny claims for end of the year profit identifies the company as heartless, robotic, and willing to do anything in order to make a buck.

Calling a hospital ICU, although unconscionable, is by no means the only practice that Unum uses to deny as many claims as it can this time of year.

However, I think we can all agree here that Unum’s robber baron claims practices and methodologies are so totally inappropriate that no employer or individual should ever buy a policy from such a company.

In the 25 years I’ve been involved with disability claims I’ve never heard of any other company doing such a thing.

Friday Q & A

Q&A ButtonWhat does Unum’s “two-year medical review mean?”

Most of Unum’s ERISA Plans contain a 24-month “change in definition”. For the first 24 months (12, 24, 36, 60), the definition of disability requires that the claimant be disabled from performing their own occupation (as defined in the national economy). After 24 months, claimants must prove they are totally disabled from performing ANY occupation for which they have training, education, or experience.

A “two-year medical review” is conducted by Unum’s internal physicians to determine restrictions and limitations taken from updated patient medical records obtained or submitted. Unfortunately, the “transferable skills analysis” that results can be inaccurate when old patient records are reviewed.

In addition, we are all aware of how unfair Unum’s medical review is when performed by physicians who are paid to support the company agenda. Finally, it’s unclear how occupations are defined in the national economy since the DOT (Dictionary of Occupational Titles) hasn’t been updated since the mid 1970’s.

In any event, it is very important for claimants to know when the change in definition will take place and what to do about it.

How many employees does Unum have?

In 2002-2003 there were approximately 3,500 employees in Portland, ME facilities alone. This did not include Chattanooga, Worcester, Glendale and the SC data center. In addition, Unum periodically has company wide “firings” and has been depopulating its facilities for the last ten years.

In my opinion, based on what I’m told by terminated employees, the company continues to fire middle-aged women (50 and over), and employees with health problems requiring the use of medical insurance. Unum has always preferred the bold, beautiful, thin, young and healthy. Unum probably has fewer employees than the 8,000 give or take the company used to have.

How is appropriate care determined?

This is actually a very good question considering most insurers attempt inappropriately to decide for themselves what is or isn’t “appropriate care.” Appropriate care should be determined by treating physicians who have a medical history with their patients and who can make decisions regarding what treatment, consultation and therapy is needed by them. It is entirely inappropriate for an insurance physician to determine how often insureds should be seen, or that treatment they should be receiving.

Having said this, there are certain medical common sense guidelines. For example, an individual who is claiming disability for depression and anxiety should be seen weekly, monthly at a minimum. Someone so depressed they cannot work, would need more frequent therapy than quarterly behavioral therapy.

Also, individuals who are prescribed pain medications and opioids should consult with physicians more often than not. A family physician should not be the physician of record for Bipolar disorder or more serious mental impairments. Insureds need to be in regular treatment with physicians who have the appropriate specialties to treat the claimed disability.

Insureds who do not remain in regular and appropriate care risk losing benefits. Insurers may decide for themselves what appropriate care is when it is evident insureds are not receiving what normally is considered appropriate care.

To resolve the issue of appropriate care, physicians should always address and document what they consider to be appropriate care in the patient records and on update forms.

BAd phone callsAlthough I’ve written several good posts about Unum’s interest in obtaining SSDI files, I think it is important to emphasize why Unum persistently requests Form 831, even when claimants do not authorize its release.

Please see the attached link to SSA Form 831:

https://secure.ssa.gov/apps10/poms/images/SSA8/G-SSA-831-1.pdf

This form is completed internally by the DDS (Disability Determination Specialist) and includes his/her name, approval listing codes, vocational information and other data used by SSA in making its determination to approve or deny benefits.

Of interest to Unum is the name of the DDS, contact information, and in particular, the listing codes used by SSA to approve or deny benefits. Unum is looking specifically for SSA mentions of “mental and nervous” determinations even if listed as secondary. Armed with this knowledge, Unum could allege the disability’s cause is mental and nervous and limit benefits to 24 months.

It is also conceivable that once Unum is informed of the DDS’ name and contact information that representatives (with Unum’s signed Authorizations) could make contact with the DDS for updates. As a rule, Unum’s general Authorization is not accepted by SSA to obtain copies of SSDI files, but it could be used as authorization for conversations with DDS’. And, no one wants Unum representatives speaking with a SSA DDS!

Unum’s contractual “interest”, if you will, should be limited to:

  • Award approval date.
  • Award amount and amount of retroactive payment made.
  • Amounts forwarded to SSDI attorneys for their services.

The above information is included on SSA’s standard approval letter. There is no reason why Unum would have an interest in SSDI files other than the above information to be used to code offsets and recover overpayments.

Although the intent of the Unum Multi-State Settlement Agreement, requiring Unum to “consider” SSDI decisions was to enforce fairness, Unum has since used the directive as a self-interested methodology to receive information unfavorable to claimants resulting in the denial of claims.

Likewise, there is no reason why ALJ notifications of “Favorable Decisions” should be sent to Unum either. Administrative Law Judge decision letters contain details regarding the 5-step review process required internally by SSA. This information is routinely misrepresented and used as part of Unum’s “stacking the deck” process to deny claims.

While SSDI approval letters should be sent to Unum as soon as received, information of no contractual interest to Unum can be withheld.

Unum’s CL-1155 (Consent or Authorization to Obtain SSDI files) is usually received by claimants with all “X’s” checked against information requested. Further, the Authorization is also “X’d” as “valid for two years.” Why does Unum need an SSDI file Authorization valid for two years?

The only explanation is that if Unum can obtain Form 831 listing the DDS’ name and contact information, the claims handler can continue to request (and share) information with SSA over a period of time.

Unum’s contracts (ERISA Plans) have no provision giving Unum any interest or authority to be able to contact a federal entitlement agency, nor does Unum have any contractual interest in having any additional information other than that stated above. So, what is Unum up to.

Clearly, Unum is extending its “contractual interest” into obtaining information related to a federal entitlement that it has no business to have.

And, here’s the real rub.

When claimants do the smart thing and authorize only the release of medical information from SSDI files, Unum sends out a letter directly to SSA that states, “If the Disability Determination and Transmittal form SSA-831 is missing from records, please advise of [claimant’s] diagnosis codes:  Primary _________  Secondary__________. Please provide this information within the next 30 days by mailing it to:…”

The above letter sent directly from Unum to SSA requests information without Authorization from the claimant! The claimant isn’t asked to sign the letter, and it requests information that was not permitted to be released on the original Consent Form.  Are you kidding me? Does Unum actually believe its claimants are not aware?

Claimants need to pay attention here. On those occasions when claimants are copied on a letter that is sent directly from Unum to a local SSA office requesting Form 831 information, claimants should notify the office directly that Unum is attempting to obtain information that was not authorized to be released.

The deceptive under handedness of Unum’s letter should give claimants a clue as to how much Unum needs the information in order to deny claims.

Be smart and think this through before giving Unum permission to obtain anything except the SSDI approval letter which they are entitled to.

Surveillance in the Christmas TreeThis is certainly the time of year when disability insurers send out the “snoop dogs” to catch insureds and claimants exceeding their medical restrictions and limitations.

While most insureds with private disability insurance are looking to buy gorgeous holiday Christmas trees, they should also be aware of the gremlins who are hiding behind them.

Noting that the holidays are times when many insureds and claimants are willing to exceed their medical restrictions, insurance surveillance toads are also ready and waiting to document what could be perceived as “work capacity.” This time of year is filled with insurance HUB investigators acting on behalf of private insurers to take your claim away from you.

Surveillance documentation, although often misrepresented, can be very persuasive since “seeing is believing.” It doesn’t matter that you went Christmas shopping, but suffered afterward; the only importance to the insurance company is that you were observed having work capacity — once.

There are certain insurers that consider surveillance a top priority — Unum, DMS, The Hartford, Guardian and even perhaps CIGNA. These companies tend to request surveillance as a normal and customary activity for every claim eventually. Unfortunately, having to tolerate surveillance, and an irritating invasion of privacy, is part of receiving benefits from any private insurer.

Although insurance companies are permitted to conduct surveillance, the results of a three-day surveillance are often misrepresented as evidence of full-time work capacity. While there never should be a time when insureds attempt to exceed medical restrictions and limitations given by treating physicians, insurers consider surveillance a sure bet for increased denials during the holidays.

Insureds and claimants are recommended to keep their eyes open for surveillance during the holidays and abide by their medical restrictions and limitations.

 

PA1959As part of Unum’s push to deny more claims prior to year-end, the company has been sending out voluminous requests to “update” SSDI applications as well as other monthly income such as pension and retirement income. Callers to DCS are complaining that although they’ve notified Unum many times about the status of SSDI applications, Unum is requesting updated information AGAIN.

These year-end requests are the result of Unum’s managers forcing claims handlers to obtain proof of SSDI status so that all claims are updated either with offsets or estimates before December 31, 2016. Remember that offsets and estimates coded into the BAS (Unum’s payment system) reduce financial reserves and provide immediate contributions to profitability.

This is also the time of year when Unum seems to place large numbers of claims on “reservation of rights” status. Although the company insists ROR doesn’t reduce financial reserve, large numbers of claims placed on ROR at strategic profitability reporting periods seems to suggest otherwise.

Unum is also pursuing updated medical information, and is requesting field visits, IMEs, as well as sending out short letters to physicians asking for restrictions and limitations. Claimants are reporting that even though they just updated their medical information, Unum is requesting it again.

It appears Unum’s focus is to gather as much “new” information as it can in order to play the numbers by scoffing up as many denials  brought to light by its internal reviewers. I’m also hearing that Unum is denying claims indiscriminately (again) forcing people to engage in expensive litigation at a time when happiness and seasonal good cheer should be bringing families together.

By the way, I haven’t noticed any other disability insurers attempting to get a “one up on” end of the year profitability. Unum is the only culprit out there deliberately intending to steal someone’s holiday cheer.

Friday Q & A

QuestionsHow often does Unum pick up mail?

Nearly all of Unum’s mail is processed through a data center in Columbia, SC. The mail is then scanned electronically, assigned, and sent directly to the desktop of claims manager and/or claims specialist. New claims are briefly reviewed and are assigned ICD-10 codes (sometimes mistakenly), and are set up on the BAS payment system. Depending on Unum’s current “focus” at the time, claims may also be subject to triage.

Mail, including incoming faxes can take upwards of 2-3 days to reach claims handler’s desks. It is not as though someone actually “picks up the mail” since the processing of incoming mail requires a large processing center. When sending mail, faxes or initial applications to Unum please allow 2-3 days for the documents to reach the claims handler’s desk. Initial applications are usually responded to in 2-3 weeks.

When can I go back to work after a period of disability?

I’ve been receiving this question quite a lot lately and the answer depends on several factors unique to each individual claim. In my opinion, returning to work requires a great deal more physical and emotional effort than just “doing the job.” Working per se, requires the ability to:

  • be somewhere at a specific time every day;
  • be able to work with others in a social context and have the physical stamina to perform job tasks as they are required to be performed by the employer;
  • have sufficient savings to invest in appropriate “on the job” attire, gas money and other expenses needed to purchase what is needed to prepare for working in a competitive environment successfully;
  • drive a vehicle safely without being under the influence of drugs that could impair you mentally or physically;
  • remain at work full-time for a long period of time. “In and out, in and out” on disability isn’t a good thing;
  • have successfully proven your ability to remain at work long-term by preparing with a “work hardening program” to test fatigue and pain levels while working.
  • be prepared to lose or lower SSDI awards and earnings offsets from benefits, or realize LTD claims will be denied.

Returning to work full-time requires the ability to perform job tasks required by employers in a sustained and consistent way. Although most insureds are optimistic about returning to work in some capacity, the reality of working is that most people will find it very difficult to be successful without first attempting a work hardening program testing their abilities for full-time work when fatigued, or experiencing low-level pain.

What’s with all this paperwork I’ve been getting from Unum lately?

Well…..here we are at the end of the year and Unum managers are requiring claims handlers to send out every request for information they can, including requests for IMEs, field visits etc. From October through December of each year, Unum’s claims reps are deliberately forced to “touch” claims, update BAS with coded offsets, request SSDI information and crazy questionnaires, and all that goes along with attempting to find every vulnerable claim that can be denied.

Unum’s claims management focus has always been to create a review process that manages claims toward denial, not payment. Therefore, the claims process itself is set up to identify claims that are easy to deny at any given point in time. I’m not sure Unum still requires “team roundtables”, but if they do, the intended purpose is to identify, what Unum calls, “quick hits” and deny them sooner rather than later. I can’t imagine the company did away with these roundtables.

Unum will do and request everything in its power to attempt to deny claims by year-end, and that is why you are receiving all of the paperwork.

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