Lindanee’s Blog – Almost There!

Readers who may be watching Lindanee’s Blog statistics should be aware that the blog is only 4,159 Visits away from 1,000,000 Reads!

This is incredible news for me in recognition of how my posts and articles are helping private disability insureds across the country. The original intent of creating the blog was to provide information to insureds and claimants equal to that of insurers who are evaluating claims.

I felt there was too much misinformation available on the Internet and that insureds should have at least one place to go to find accurate and reliable information. These goals and objectives are still a priority to me in providing paid consulting services as well as information to the general public.

I am so pleased to achieve such a milestone number of Reads and Visits. Thanks to everyone for helping me follow through with the goals I’ve set and the opportunity to offer accurate information to the public. It’s been a very rewarding experience.

Needless to say, I plan to celebrate when the blog actually hits 1,000,000!

 

Unum Breach Of Contract – SSDI

Unum’s ERISA group plans contain SSDI provisions requiring claimants to apply for SSDI and “keep the process going” to avoid estimates and early offsets. Claims handlers quickly become annoying because of their constant chasing for SSDI status updates to ensure offsets are taken and benefits are reduced soon after approval letters are received from SSA.

Of late, however, Unum is estimating SSDI and reducing benefits despite information provided to it by claimants that the process of applying for SSDI is continuing. Threatening letters are sent to claimants that estimated offsets will be taken if information is not received. Even when SSA update letters are received Unum is estimating offset reductions from benefits, which by the way, reduce financial reserve and contribute to profitability.

Simply put, Unum’s Plans do not allow Unum to offset benefits with SSDI offsets, IF the claimant is continuing the process of appeal though the Administrative Law Judge hearing, or is re-applying for benefits.

I received several phone calls this week from claimants who have been harassed by Unum for SSDI updates already sent only to have their benefits reduced for estimated SSDI anyway. Unum is not abiding by the Plan document that writes claimants can avoid estimates if they follow through with SSDI appeals and the process in general.

Is Unum misplacing proof sent to it by everyone, or is it more likely that taking estimated offsets is a deliberate focus to bolster its profitability for year-end? In addition, the really awful thing is that when claimants are denied SSDI benefits Unum doesn’t give the money back alleging, “it’s obvious you would have been awarded anyway.”

My money is on Unum having a deliberate focus to estimate benefits for SSDI in clear violation of Plan provisions. In one instance, one of my clients (with my assistance) challenged Unum’s SSDI breach of contract and demanded the estimate taken be returned to her with interest. It was.

When challenged on this issue Unum doesn’t have a leg to stand on when Plan provisions are cited as back-up. Again, Unum cannot, via most Plan provisions, reduce benefits with an offset for SSDI unless the claimant refuses to apply, or doesn’t continue the process through with at least two levels of appeals – reconsideration and Administrative Law Judge.

Unum’s arrogance in blatantly and openly breaching its Plan contract is astounding. Claimants should always check their Plan or policy provisions for what it actually says about any issue raised by Unum.

It’s getting to the point where the company can’t tell the truth about anything.

Friday Q & A

Can Unum, or any other insurer deny claims after SSDI is awarded?

Of course they can. In fact, Unum’s false flag of assuring you the company wants to “give your claim every possible consideration” is obviously untrue since Unum rejects SSDI information in favor of its own misrepresented medical views. It’s an interpretation of the old “bait and switch” marketing ploy. Unum presents its intent as honorable while the real interest in SSDI information is to discover Form 831 information it can use to deny claims such as mental and nervous listing approvals.

In addition, once Unum has claimants believing SSDI information will help them, claims are still denied but this time the company says, “We considered information from your SSDI file but we have more current information that Social Security didn’t have at the time you were awarded”, hinting that perhaps you shouldn’t have been awarded SSDI in the first place.

As I’ve said many times on this blog, disability insurance and SSDI is the most infamous estoppel there is since insurers first force claimants to apply and then they use the information to deny claims (not to mention that insurers take retroactive SSDI awards first).

I just read a letter from Sun Life to a claimant explaining how different their policy language is from qualification for SSDI. If this is true, then how is it their representatives can force people to apply? Either claimants are totally disabled and meet SSDI criteria, or they don’t. Which is it?

Yes, insurance companies can deny disability claims when SSDI is awarded. Not only can they do this, but most insurers have developed “safety net strategies” so that they benefit, rather than not from the process.

How do I know whether I owe Unum an overpayment when they inform me of it but won’t prove or show me the calculations?

I am unfortunately aware that this is going on at Unum; and, I suspicion it’s the involvement of Lucens who is most likely financially reviewing claims looking for the $1-$2 overpayments due to miscalculations. It should be somewhat troubling if not suspicious to insurance regulators that there are so many “mistakes and errors” suddenly uncovered.

There are many people receiving “overpayment” letters ranging from $60 overpayments to into the tens of thousands. Doesn’t it seem odd that a company like Unum would have made so many calculation errors that need to be corrected? In addition, letters are going out to insureds and claimants that errors have been discovered and deductions will be made from benefits.

There is no effort on the part of Unum to provide copies of the actual calculations, prove or validate that any amount is actually owed. Therefore, before anything is paid back DCS, Inc. is recommending that insureds and claimants notify Unum in writing they wish to receive proof that the overpayment is actually owed. This would include spreadsheet calculations, or any financial data relied upon by Unum to allege additional monies are owed.

ERISA folks can actually appeal Unum’s overpayment allegations and request disclosure proof be provided prior to offsetting benefits. In today’s business environment it is astounding to me that any insurance company would presume to get away with “taking money from benefits” without first proving it was owed. In what other business would a customer actually give up money for a debt that is not proven?

It also should go without saying that anyone who actually believes what Unum says about anything should come to Maine and buy some marsh swamp land developers have for sale.

Unum is sufficiently discredited in the public’s view that it is reasonable for all insureds and claimants to insist on seeing the actual calculations before agreeing to reduce benefits for an “alleged” overpayment.

Unum’s say-so, should essentially be a no-go.

 

ERISA – One Step Forward Two Backward – An Urgent Read

For those of you interested in ERISA it seems clear that for every proposed improvement in the law, there are two negative reverses for claimants.

Unum, of course is a primary challenger of the the many proposed changes that will even the playing field in a now extremely unfavorable administrative and legal dilemna.

I’d like to remind the US Department of Labor that during the Multi-State Settlement investigations, memos were found whereby executives such as Ralph Money and Harold Chandler specifically documented how the company was making $millions off of ERISA denials. Once again, it’s all about the money, and the DOL needs to realize that.

Unum’s lobby contends (lobby also extends to Congress by the way) that the new proposed changes are too cumbersome and costly, nearly to the point of forcing insurers to drop disability lines all together. Such fear mongering might win Unum strange bed fellows in Congress but unless the proposed changes go through next year, the door will be left open for Unum, and any other disability insurance company to continue to abuse ERISA Plan participants for profit.

Unum Group should be viewed as “the beast in the forest” for suggesting that the new proposed changes should not take place. How cumbersome and costly can it be to make changes in the claims process that are fair, objective and equitable for all claimants?

I’m suggesting that every ERISA claimant in this country should respond to the US Department of Labor with their case histories. (Unum claimants in particular.) A non-response from the public regarding these issues will place all ERISA Plan participants “up chits creek” allowing insurers to continue to abuse the process of review.

I find it particularly naive of any insurer to think they will EVER be able to sell another group plan while opposing the changes below. This issue belongs in the court of public opinion and the truth about Unum and other insurers needs to be told.

I’m not sure where  claimants can send responses yet, but when I know I will publish it here. If anyone else knows please send me an email and I will incorporate it in to this post.

I’m not surprised Unum is leading the pack of wolves opposing ERISA changes. There’s more money in cheating claimants than there is in being fair within the claims process. People need to respond to the call for comments and let the DOL know you support the changes and why.

Here are the issues and what you possibly could lose.

(Reposted from ERISAlawyer.com)

The Proposed Delay Of The Effective Date Of The Final Rule.  The U.S. Department of Labor (the “DOL”) has proposed a delay for ninety (90) days – through April 1, 2018 – of the applicability of the Final Rule which amends the requirements in the ERISA claims procedure regulations that apply to claims for disability benefits.  The proposal is here.

The Final Rule was published in the Federal Register on December 19, 2016.  It is currently scheduled to apply to claims for disability benefits under ERISA-covered employee benefit plans that are filed on or after January 1, 2018.

Expanded Requirements.  The expanded requirements pertaining to disability claims include:

• 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.
• Benefit denial notices must include a statement that the claimant is entitled to receive, upon request, the entire claim file and other relevant documents.  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.
• Plans may not deny benefits on appeal based on new or additional evidence or rationales that were not considered when the benefit was denied at the claims stage, unless the claimant is given notice and a fair opportunity to respond.
• Plans 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.
• 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. This allows the claimant to proceed to court immediately, and the court will not provide any deference to a decision by the plan administrator when reviewing the case.
• 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.

Questioning The Final Rule.  Following publication of the Final Rule, various stakeholders and members of Congress asserted that it will drive up disability benefit plan costs, cause an increase in litigation, and in so doing impair workers’ access to disability insurance benefits.  Pursuant to Executive Order 13777, the DOL has concluded that it is appropriate to give the public an additional opportunity to submit comments and data concerning potential impacts of the Final Rule.  The DOL will carefully consider the submitted comments and data as part of its effort to examine regulatory alternatives that meet its objectives of ensuring the full and fair review of disability benefit claims while not imposing unnecessary costs.

The DOL accordingly seeks public comment on the proposal to delay the Final Rule, in order to solicit additional public input and examine regulatory alternatives.  If, based on the comments received, the DOL decides that it will implement the proposal, the amendments made by the Final Rule on December 19, 2016, would become applicable to claims for disability benefits that are filed after April 1, 2018, rather than January 1, 2018.

Posted in: ERISA

A Surveillance Suspicion

I received this case by email this morning and I’m posting it here because I’m sure my answer will help others as well. Thank you to the person who sent me his/her story. It often takes courage to share disability experiences and I want to acknowledge how important you are to others and to the process.

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I am a huge fan of your blog, whose guidance has proved invaluable during my horrific adventure with long-term disability.

My concern over the past couple of months or so is that I feel as if every one of my visits to the gym has been monitored, either by someone taking video with a cellphone or with a wristwatch phone, or more recently someone simply watching me and then taking a surreptitious photo of me with a cellphone at the end of the workout.

I only go to the gym for classes and to swim. My disability is a serious mental health issue for which my psychiatrist “prescribes” in addition to medication and psychotherapy, a regular exercise routine. So I’m not doing anything that I shouldn’t be doing. But it is extremely unnerving to feel as if I am being watched and videographed/photographed every single time I go to the gym.

Now my therapist, pushing back against my paranoia, tells me that I’m just not that important for the insurance company to have me surveilled for such a long period of time. Before you agree, let me lay out a theory.

My theory is that the insurance company has contracted surveillance from a boutique private investigator who specializes in surveilling this particular gym network (only about a half dozen gyms within a tight geographic area). He spends a lot of time at the gym and coordinates with free-lancers, all of whom have gym memberships, and they are conducting surveillance not just on me but on a number of people on disability.

This spreads out the cost and because the focus is on the gym, you don’t have to worry about the high-cost, high-risk undertaking of following people one by one. It’s more like shooting fish in a barrel.

If this is true — and I fully embrace the possibility that I am just being paranoid, because, well, paranoia is a feature of my illness — it is especially creepy because you are always under surveillance (not just over a three-day or seven-day period) and you are being surveilled by your fellow gym members (and I suspect a handful of gym employees who are helping out).

The way this appears to work is that the person(s) doing the surveilling will arrive late to the class (after you have claimed your spot). They take water breaks at odd moments, spending a suspicious amount of time with their phones or holding their Apple watch at just the right angle while you continue your workout. Then when the workout is over, they will follow you out with their phone/camera. My strategy is to wait to be the last one out and it is always a waiting contest with the suspected surveillance gatherer, who waits until she can’t wait any longer.

Although this is an ingenious system, if true, I feel it is a huge violation of my privacy. Indeed, the fitness manager assured me about a year ago, in writing, that it was against gym policy for members to take video of other members without their express permission.

It’s even more a violation because the gym network is affiliated with a hospital and offers physical therapy and nurse checkups as part of the membership. It specifically markets to people with injuries/disabilities!

I have become afraid to go the gym and when I do go I feel so stressed out that I end up feeling worse rather than better after a workout.

Do you have clients who have expressed a similar concern or do you think I am simply being paranoid? I don’t feel that everyone is surveilling me. There is a group of about six people who are consistently behaving suspiciously.

I noticed somewhere on your site that you offer a minibook on surveillance to your clients. Alas, I am already paying a (wonderful) lawyer and can’t afford to hire you as a consultant in addition. Is there anyway you can offer your surveillance book for sale?

Thanks in advance for any advice you can give. If you want to publish my letter in part or whole you have my permission but please do not provide any identifying information about me (i.e., my email moniker, etc.).

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Again, thank you for sharing your experiences with me. Although I usually defer people back to their attorneys for information when they have one, I’m choosing to answer your concerns anyway because your story could easily be someone else’s.

To begin, insurance companies are all about the money. A three-day surveillance team might charge from $1,500-$2,500 for each surveillance request. The constant surveillance you suggest would require that you are receiving more than $5,000/month benefit. This doesn’t mean that your insurer has not conducted surveillance, but it does mean that I question whether any insurance company would incur the high costs of surveillance for non-wealthy claims.

In the normal course of using surveillance, insurance companies request a three-day surveillance, usually Thursday, Friday and Saturday for the “quick hit” to back-up an otherwise weak denial. Placing investigators under cover in a particular gym suggests that the insurance company is seeking far more information than it really needs to deny a claim. And again, it would be pretty expensive to do this kind of thing.

Insurance companies do not have the means, nor the wherewithall to install permanent investigators in a particular gym. Insurers are not the CIA and they don’t conduct covert operations per se. It’s not that your claim is unimportant, it’s that insurers do not spend the kind of money it would require to set up under cover investigators at a particular location.

The fact that you have a behavioral claim rather than a “physical one” also tells me that your therapist has an excellent opportunity to document the fact that regular exercise at a recommended gym is part of his/her treatment plan to return you to health. It can be documented in patient notes and recorded on the update forms you return to your insurer. You do not have to be afraid if you are following through with your therapist’s treatment plan and recommendations. In fact, your psychiatrist can actually write out a prescription for you to exercise in a certain way at a gym.

Bottom line, insurers will not spend the kind of money you are suggesting here to permanently hire surveillance at a particular location, nor are they likely to engage in surveillance for more than three days. I’m not suggesting insurers only conduct surveillance once, but they do it in different intervals of time.

I encourage you to speak with your psychiatrist about documenting your exercise regime into the patient record and also including it in a written treatment plan. In addition, remember that your time in the gym is in fact a mental health requirement and that any insurance company would find it very hard to deny your claim when your provider is recommending that you do it.

I really can’t provide copies of my proprietary material to those who are not clients, particularly those with attorney representation. However, if you consider the above answer I think you will know how to handle your time in the gym medically, and present it to the insurance company as a credible part of your treatment.

Thank you again for sharing your case history with me and about 800 daily readers of Lindanee’s blog. If you have any other questions please feel free to contact me.

Friday Q & A

Can Unum send a representative to my house?

What you are referring to is called a field representative visit, and “yes” they do ask to visit you in your home. HOWEVER, you don’t have to allow the reps into your home at all.

If your policy requires you to submit to a field visit, you may ask to meet with the representative at a public place such as MacDonald’s, Wendy’s or a local coffee shop. The purpose of Unum’s asking to meet you in your home is to enable you to “talk” and “feel more comfortable”  potentially sharing information Unum has no right to ask, or know.

Visits allowed to take place at home usually last a great deal longer, such as two-three hours while visits in public places only last for about an hour. The field investigator is a professional profiler who writes in his/her report about your home, how you are living.

When I went to “Unum school” years ago, the instructor, and head of SIU (Special Investigations Unit), described various means of “trickery”.

For example, on the day of the visit in her home one insured described how she had to use a cane to walk all the time and had also placed a very conspicuous cane leaning against her table. During the interview, the Unum investigator asked for a drink of water and the insured walked up three steps to the kitchen to get it, forgetting her cane.

Another example included an insured who was alleging he had severe cognitive issues and couldn’t take care of his finances. The rep pulled out all of the change he had in his pockets and asked the insured to count it, which he did perfectly. Oops!

DCS, Inc. does not recommend field visits take place in anyone’s home for all of the above reasons. There are several other posts on Lindanee’s blog dealing with field representative visits. If you search from the home page you will find more details on the subject.

Are we allowed to see what Unum’s investigator’s write?

No. You may have access to the report after your claim is denied which is something you do not want to happen. Northwestern Mutual will send out a synopsis, but it isn’t the same report that goes into the record. ERISA insureds aren’t entitled to see anything in the Administrative Record until the claim is denied. IDI insureds have no right to disclosure and insurers may or may not send copies of the file at the time of termination.

What does ERISA have to do with pre-existing conditions?

The answer is quite simple – nothing. Group Plans and policies contain provisions that describe under what circumstances claims would be considered pre-existing. Although there are many types of pre-existing conditions, ERISA doesn’t deal with the issue directly, or more so than any other provision in the policy.

The courts have considerable influence over what is and isn’t a pre-existing condition.

Can Unum deny STD benefits?

Of course they can, and do, on a regular basis.

In the past STD was viewed as a “sure thing” since no financial reserve was required for that line of business. However, Unum’s management is now aggressively managing STD and denying more claims than ever. Unum’s motto? “Deny sooner rather than later.” It’s generally accepted at Unum that it’s better to deny the shorter 26 week STD claims sooner rather than to inherit the more expensive LTD liability to age 65.

 

Unum – Use Of Medical Advisor To Set Recovery Dates

In the past the people of Great Britain suffered because of its welfare system’s use of something called ATOS, now discontinued. Those who applied for “disability welfare” were determined eligible, or ineligible, by a computer system (ATOS) with no human intervention. Amidst a great deal of protest and civil action, ATOS was eventually done away with.

Meanwhile in the United States, Unum (the co-inventor of ATOS), also uses a computer software called Medical Advisor (MA) to determine “when insureds SHOULD be better”.

Of course, MA doesn’t take into consideration that people improve and “get better” at different rates, and I suspect the use of MA allows the company to reduce its medical staff and require fewer RN walk-ins. I also suspect Unum may be using MA to set ERDs (Expected Recovery Dates) that are really drop dead dates for claim denials.

Recently, I received an email from someone who had been admitted twice as a mental inpatient for two attempted suicides. Diagnosed with schizophrenia, Unum continues to harass him since “he should be better in 12 weeks.” This kind of statement reeks of Unum’s use of Medical Advisor that also assumes the program is used by medically savvy claims handlers.

To my knowledge schizophrenia does not go away in 12 weeks and it is extremely inappropriate for Unum to allege this claimant can go back to work without restrictions. Having used MA myself when I was employed by Unum, it seems to me one of Unum’s village idiots looked up depression and anxiety and got 12 weeks.

Unum’s management is extremely remiss in allowing claims handlers to use Medical Advisor without adequate training. It is also acting in bad faith, if in fact the review process uses MA to set future recovery dates – really claim denial dates in disguise.

Rumors continue to abound that Unum Group downsized again and is cutting corners on the review process to the point of negligence. I heard several months ago that Unum trains its newbie U-numbies to “suspect” every claim and investigate as much as possible.

This is a philosophy that came to the company via Harold Chandler, Ralph Mahoney and his henchmen from Chattanooga in 1999. At one time ERDs were connected to financial reserves so you can see how important it was to use MA and set ERDs to the shortest period of time.  Fortunately, for insureds and claimants Unum’s ERD fiasco was discovered and ERDs were removed from financial reserve coding.

Nevertheless, it appears that Unum is once again using a medical coding software to pinpont (target) when claims can be denied. Using artificial software to determine human recovery dates isn’t accurate and Unum should know better since it never really worked the first time around.