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Phone CallsLately I’ve been receiving large numbers of calls from non-clients who have various questions about their claims. Although I do not have an awful lot of time to answer questions from those who are not clients, I’m finding that when I try to call insureds back, they do not answer their phones, or have mailboxes that full etc.

Please. If you call me to ask questions, please make sure you are available to answer your phone. Or, you may tell my answering service when you would be available to pick up the phone and I will call you back at that time.

It’s my policy to call non-clients once. If you do not pick up the phone I may not call back. Although I try to help as many people as I can, I do not have the time to keep calling back. You may also send me an email suggesting questions for Friday’s Q&A.

I am trying to help those who are not clients as best I can, but I just don’t have the time to keep returning calls to those who have questions and won’t answer their phones. Thank you for your understanding.

Review the situation(DCS received an email with the question below. Please see my answer.)

Unum has sent me a form requesting social security and employment information regarding my spouse, they ask; Am i currently married, what is my spouse’s birthdate, employment or previous employment and how many years, is my spouse receiving social security benefits, etc. I am in my early sixties and have been on UNUM benefits since the early nineties. My social security benefits are already on offset since the beginning. Although they may assume my spouse is nearing social security retirement age (and my spouse is much younger), I don’t read in my benefits book where I would have to include my spouse’s social security information in their form nor would those benefits (if there were any) be subject to an offset!

My son’s Family Benefits are also being offset and he is turning eighteen soon and that offset should terminate when I send Unum that notice. Certainly I shall send them the Social Security termination notice of Family Benefits for my son when I receive it, but how do I reply to the spouse question? Thank you Linda for being a valuable resource.

This is a very common misconception regarding SSR (retirement income) from spouses. While it is true Unum’s forms do ask for the name, SSN, and birthdate of a spouse as well as dependents, the question is intended to determine if a non-working spouse is receiving dependent SSDI, although I’m sure the information is also used in malicious ways.

Spouses are not parties to the disability policy or Plan. They are not required to provide any personal information about themselves such as SSN or birthdate although insurers may get a bit smart about it and request tax returns that contains spousal information.

Insureds and claimants are not required to submit tax returns unless they are residually working, or have DI policies requiring the computation of PMI. (I recently discovered a Mass Mutual policy that actually contains a provision requiring the submission of tax returns.)

Therefore, when asked to provide spousal information a simple comment of, “This information is not relevant to my claim” can be written in. Of course, if a spouse is receiving dependent SSDI, then you are required to inform Unum of the same.

SSR, or retirement income of a spouse is not an offset and need not be reported. This is an issue that comes up when insureds have been on claim for a long time and they begin to reach normal retirement age.

Depression2Nearly all generally accepted claims practices established by the National Association of Insurance Commissioners (NAIC Model Acts) and the Employment Retirement Income Security Act of 1974 (ERISA) require insurers to review claims in “good faith and fail dealing”.

In addition, ERISA establishes “fiduciary relationships which require both the employer and Plan Administrator to “decide indeterminable issues in favor of the claimant”. Unfortunately, although the concept of “good faith and fair dealing” is a part of every recommended disability claims practice, it isn’t law and cannot be enforced, although nearly all of the states recognize the Model Acts.

The opposite of “good faith and fair dealing is “bad faith” that can, of course, be decided by a jury. ERISA folks are unfortunately left with conflicts in federal court about which “standard of review” the judge will use in determining the case in review. Even though bad faith exists ERISA claimants are deprived of the opportunity of offering it as an argument in support of their legitimately payable claims.

The point is that there are rules and accepted claims practices insurers are required to follow in evaluating disability claims and making decisions as to whether to pay or not pay claim. Some accepted claims practices mention “fair, objective and equitable review”. Still, in the last decade, Unum Group continues to devise deliberate claims review processes that deprive insureds and claimants of anything close to fair and equitable claim review.

In 1999 after the Provident  take-over of Unum Life Insurance, whistleblowers exposed the new company’s deceptive claims practices to the media and all hell broke loose.

Interestingly, public exposure of Unum’s internal processes is happening again. Terminated Unum employees are contacting members of the press and media and thankfully have included DCS, Inc. in the information thread.

The information provided here may or may not be exactly described by employees in Chattanooga at the time it was reported to DCS, Inc., but it will give readers a sense of how far Unum goes to deny as many claims as they can. Unum’s claims process, as described by those who worked for the company, deliberately targets claims on a grand scale and then harasses its claims specialist until the claims are actually denied.

Whether or not Unum’s claims process today is exactly as described, it does presuppose that Unum, whatever system currently in place, continues to target and deny claims unfairly.

THE TARGETING WAREHOUSE – IMT SHEETS

As was always my experience with Unum, its business is managed by establishing claim financial reserves which can be manipulated to show profits which do not exist. As you may recall from other posts “financial reserves” represents money put away equal to the value of each claim as a buffer to be able to pay it. Financial reserves create liabilities (losses) but when removed create profit. There is no financial incentive to pay claims.

Although Unum consistently alleges it does not keep financial reserve claim data, former employees tell me that managers and VP’s continue to have access to reserve information. Unum claim and claimant data is stored on a system called “Navalink”, therefore, all managers and VPs (Quality Compliance) can view claims at random and compile “targeted lists” of claims, presumably those with the highest financial reserves referred to as, “the biggest bang for the buck.”

Claim managers then place the names of their targeted insureds and claimants on a sheet called the IMT sheet, or Integrated Management Technology. As described to me by Unum employees, IMT sheets are very similar to OMAR spreadsheets used in the past to target claims.

I’m told that everyday managers visit each claims handler in their cubicle and give them an IMT sheet containing names of insureds and claimants to “focus” on that day. It seems reasonable to me to presume this sheet also contains the names of claims with ERDs (Expected Recovery Dates, or “dates we intend to deny these claims) on it.

I’m told that throughout the day, claim managers hassle claims handlers in their unit to declare progress toward denying (resolving) claims listed on the IMT sheets. The IMT sheet targeting process on certain claims is indicative of unfair claims practices because it deprives insureds and claimants of a “fair and equitable review” based on the unique circumstances of claims.

It is also not unreasonable to conclude that once a claim is targeted and placed on the IMT sheet, it will not be removed regardless of what additional information is submitted to the company as proof of claim. This may be why claimants report that medical support of claim is ignored for some while others are approved and paid right away.

IMT sheets demonstrate Unum’s claim targeting process because it is the claim managers, VPs, and Quality Compliance who have access to financial reserve information and who goes on the “sheet” and who doesn’t. Finally, pressure placed throughout the day on claims handlers to continually deny claims clearly indicates a targeting process.

Whether or not Unum continues to use IMT sheets today is not important because its my opinion that Unum continues to target claims regardless of what it calls its current system of “claim focus.”

THE 2 OUT OF 3 RULE

Former Unum employees also describe a “2 out of 3 rule” to provide back-up for claim denials. Again, even if Unum is no longer referring to the process as the 2 out of 3 rule, in keeping with its track record, internal process remains the same but the names are changed to hide them in plain sight.

If claims handlers can convince treating physicians, vocational representatives, employers and others to say insureds are able to return to work, claims are denied when 2 out of 3 resources affirm.

IN RETROSPECT

To be clear, the above information was provided to DCS a few years ago from terminated employees who contacted us to share the information. However, there is no indication by letter or file documentation that the company has over time changed its claims process to pay claims rather than finding reasons to deny. The company  often changes the names of its processes to hide them in plaint sight, but they exist nonetheless.

Those attorneys who now say, “Unum is better now than it used to be” need to open their eyes and get into the trenches with non-wealthy claimants and listen to what they have to say. From my perspective Unum has NOT changed its targeting focus and remains an unfair insurer.

Disability insurance is not what most middle class Americans think it is, and filing claims, not just one with Unum, but any disability insurer, quickly becomes a confusing and complex process that often does not end with paid benefits.

In today’s insurance environment there is nothing about disability insurance that is “fiduciary” in nature, or applied in “good faith and fair dealing.”

One has to remember after all that “targeting claims” for the “biggest bang for the buck” is an unfair claims practice that Unum has gotten away with for quite some time. Insureds and claimants should always be smart, sit up and take notice, and act accordingly.

SurveillanceThis is just a reminder that along with good weather and summer fun insurance surveillance may be watching you. Disability insurers are well aware that insureds are likely to push the limits of documented restrictions and limitations and step up surveillance activities.

While surveillance is a way of life for those receiving disability benefits, insurers take advantage of holidays such as Memorial Day, 4th of July and Labor Day to “catch” unsuspecting insureds enjoying themselves with family.

Outings such as picnics, days at the beach or lake, 18 holes of golf, swimming etc. are strenuous activities that may be medically restricted. As a general rule, insureds on disability should never be observed exceeding medical restrictions and limitations previously reported to insurance companies as activities they may never do, or are able to do, but to a limited extent.

Insureds should be aware that the excuse, “I have good days and bad days”, is not a persuasive argument to defend engaging in medical activities not allowed. Also, the response, “But, I paid for it for a week afterward”, is a lame excuse for exceeding medical restrictions. No insurance company believes that!

I sincerely hope insureds and claimants are also aware that describing family activity on social media such as FB, and Twitter, My Space etc. is not a good idea. Although DCS recommends insureds and claimants stay off of FB altogether, I also realize not everyone follows best advice.

Those who have given their insurers a cell phone number, beware. Investigators can track you on your phone or plug-in to your whereabouts. Although I realize the trend is for people not to have LAN lines these days, it isn’t a good idea to put your cell phone number on insurance forms. Amazing things adverse to claims can happen with cell phones these days.

I hope everyone has a great upcoming holiday and summer, but please do not push the envelope of medical restrictions and limitations.  I’m assuming everyone still wants to have their benefits by Labor Day, so be smart and abide by reported R&Ls.

ComplaintsElizabeth of Liverpool, NY on May 5, 2016

I’ve been having issues receiving payments from Unum Insurance Company. Since 2007 they have been recouping income from me in regards to 3 payment of 1739.52 which Unum had sent. They had refused to remove the family disability, when I no longer had dependents for social security family in 2012 (Unum finally removed the 18-yr-old as receiving family income on their budget calculation). In 2009 I had lost workers comp payments. Appeal was put into the comp board and I won back payments in 2012 so comp gave me back payments for that time to 2014. I still was not receiving any payment from Unum due to a recoup, yet again Unum added an additional recoup amount to what they were already being recouping In 2007. I received the max in Social Security disability and workers comp from 2012-2014 and Unum was paying me the minimum balance of $173 which they had been recouping since 2007.

2014 Unum sent me a settlement offer and I declined the $16,000 minus $6000 overpayment they claimed I had owed, but in the same token they sent me a check for under $2000 a few days later because they claimed I was underpaid by them. So I cashed the check after I called Unum to make sure that it was not going to be an issue if the checked was cashed. I was told by Unum representative that it was my money owed to me from an underpayment by Unum and for me to go on and cash the check. Representative stated it was ok to cash the check (biggest mistake ever on my part because they used that as a reason to recoup). In 2014 I decided to settle. I decided to take the lump sum instead of the bi-weekly payments from workers comp. Unum sent me a letter stating that there was an overpaid by them. Mind you Unum is still only paying me the minimum amount $173. But the recoup payment was close to $10,000.

Today I received a call from Unum,. I was told by them that my settlement offer from workers comp which was a one-time payment of me forfeiting all future payments from workers comp and will never receive another payment from worker comp. Well Unum says that my settlement amount in 2014 was backpay from workers comp from 2012-2014. I asked the Unum representative how could my settlement be a backpayment, when I was getting a bi-weekly workers comp check from 2012-2014 and had not received any money from comp since 2014 to current. And how do I owe back several thousands of dollars when your company has only been paying me the minimum of $173 and has been recouping since 2007. In my case Unum has been recouping on a recoup so they don’t have to pay me any benefits I’m entitled to.

Unum also told me today they are going to contact workers comp and they may have to go back 2012-2015 and I may owe them money. How is that possible? When In 2012 reinstatement of my works comp claim they gave me a 1-time backpay in 2012 to cover income lost and thereafter workers comp bi-weekly check until 2014 settlement. Unum has received all income verification documents in a timely manner of any changes in income from all parties, workers comp & myself included.

(Unum seems to be trying too hard to find money owed to them that doesn’t exist. I’ve had several people call me with reports of Unum alleging money is owed when it isn’t. The above situation is consistent with other reports I’ve had and therefore leads me to believe that one of Unum’s “focus activities” is going on in their financial departments to locate unclaimed money alleged to be owed.

Another problem here is that Unum’s reps rarely read the entire file and base their allegations on parts of the file they choose to read that are favorable to the company. One department at Unum may not be aware of what other departments are doing either. Unfortunately, activities taken on particular files depend on who is reviewing them and there is no consistency throughout the claims process.

Reports of using the settlement area to continue to risk manage claims may give Unum increased opportunities to challenge what was paid and what should have been paid. My recommendation is not to pay anything back until Unum provides you with a complete spreadsheet of all payments and offsets made to date. Then,  have the information checked out by an accountant or lawyer.

Unum’s attempts to find money owed is an indication of a dedicated “focus”.  Facts seem to indicate that most of the money Unum finds is an Aesop’s Fable and isn’t owed at all.)

Friday Q & A

QuestionsHow can I obtain a copy of my SSA Form 831?

SSA-831 is the official disability determination form used by Disability Determination Services (DDS). One copy remains with you file and other copies are sent to other SSA offices although no copy is sent to you. Information on the form includes codes used by SSA, and the name of the DDS disability examiner as well as the DDS medical consultant who worked on your claim.

You can obtain a copy of SSA Form 831 by sending a letter to your regional SSA office requesting a copy, or you can request an entire copy of your SSDI file. Once you receive the information you should note the name of the medical consultant who signed SSA-831 and the specialty code near his/her name. For example, mental impairments are always evaluated by a psychiatrist or psychologist.

SSA-831-U3 is also completed for claims on reconsideration.

I have no doubt this is the reason why Unum, in particular, is very interested in obtaining SSA-831. The company is attempting to determine whether your disability is due to a mental or nervous disorder. If SSA-831 indicates your claim was reviewed by a psychiatrist or psychologist, Unum may limit benefits to 24 months.

This is why Unum is so anxious to obtain SSA-831. I also suspect Unum may have the intention of communicating with DDS and medical examiners which is a line that no corporation should be allowed to cross for a federal entitlement. SSDI claimants should fight to keep Unum out of the government’s business.

Can insurance companies insist on receiving psychotherapy notes as proof of claim?

Today, therapists and mental health providers recognize the fact that disability insurers abuse psychotherapy notes by “snatching” key words and phrases favorable to them at the expense of all else favorable to insureds. As a result, most therapists identify “psychotherapy notes” as proprietary and refuse to release them to any outside third-party. In this respect, insurers shoot themselves in the foot with misrepresentation of therapy notes resulting in refusals to submit them.

There is no policy I am aware of that specifically requires therapy notes as proof of claim for mental and nervous insureds. There are, however, broad sweeping provisions that could include “any other information we request.”

Prudential is the main offender of abusing psychotherapy notes mostly reviewed by unqualified RNs who pick and choose key phrases to hold against insureds. Although actual psychotherapy notes are not contractual requirements specifically, therapists are still required to provide mental restrictions and limitations in summary form – either in a letter, or by filling out a form.

Prudential will deny claims without actual psychotherapy notes even when therapists refuse to submit their own proprietary information. Also, therapists should be very careful not to release therapy notes when Unum submits signed Authorizations that clearly say, “(does not include actual psychotherapy notes).

Insureds should speak with their therapists and mutually agree how to handle requests for psychotherapy notes. Most therapists refuse to hand over personal notes when they are aware of how they will be used against their patients.

What is a Unum HUB field interview?

According to its website HUB markets itself as a “full service insurance defense investigative firm.” Oops, here we go….”insurance defense”, and by the way, that’s not you.

HUB Enterprises offers their services in the United States and internationally. Services include, surveillance, activity checks (knocking on your neighbor’s doors), claim investigations, subrogation investigations, field visits, recorded statements, contestable death investigations, medical records retrieval, premium fraud, avoidance, medical investigations, hospital checks, chiropractic checks, special investigations, insurance fraud compliance, fraud prosecution, anti-fraud plans, continuing education and fraud training, investigation of suspected fraudulent claims, database investigations, background checks, asset/real property checks, motor vehicle reports, drivers’ license information, civil & criminal records, SSN search, Internet social site search, marriage/divorce records checks.

When you are sitting across the table from a HUB investigator you are being subjected to an up-front, in-your-face, personal profiling process for the purpose of “investigating” claims on behalf of an insurance company. These interviews are not friendly “chats” about your claim, but are deliberate attempts to coerce insureds into verbally giving away “inconsistency of report.”

Attorneys who advise their clients to submit voluntarily to out-of-contract HUB interviews have no idea what they are setting their clients up for. If there is no specific contractual duty to subject oneself to such an interview, it would be unwise to do so. Those who continue to use social media despite my recommendations against should definitely take another look at the above list.

How would you classify Unum Group in comparison to other insurers?

In my opinion, Unum Group is now one of the “bottom feeder” disability insurers along with CIGNA, MetLife, Prudential, Aetna and Reliance Standard. Unum’s only popularity is that the company is known as an “outlaw company” and continues to target and deny legitimate claims. The company continues to instill fear into many of its insureds with threats, harassment and intimidation.

Since the 1999 merger with Provident and Paul Revere, Unum’s review process continues to harm disabled persons for profit, sells insurance Plans to employers it has no intention of paying out on, harasses medial treatment providers, misrepresents patient medical records, and attempts to eliminate claimant access to support and resources to avoid payment of claims.

While other insurers also engage in the same practices Unum leads the industry in numbers and has the greatest potential for harm. This pretty much says it all.

 

 

 

 

DepressionIt is always very hard for me to receive calls from insureds and claimants who have recently been devastated by notifications of claim denials. I think because of the blog people regard me as someone who will listen to them when they have no one else to turn to. And, I do listen.

Today I received a call from a gentleman who was told by a Prudential claims rep that his claim was denied because the recent IME results indicated the evaluation wasn’t valid. Rather than waiting to retest him, Prudential suddenly denied the claim leaving Mr. T. without any financial resources at all. Although he applied for SSDI, he is now on appeal and wonders how in the world he is going to put bread on the table for his family.

“I don’t know what I’m going to do now”, he told me, “I live in Connecticut and I need this money to cover my expenses. This was all of the money I had in the world.” (Mr. T. already used up his 401(k) money to cover other expenses.)

I’ve been publishing posts on my blog for about four years now and have repeated articles informing people who have private disability insurance that it is NOT a guaranteed benefit and that they should carefully consider having a Plan B in place long before an unforeseen disability occurs.

Despite this blog, or what Linda Nee posts, I’m sure there are thousands of Americans who continue to put their faith and financial security into disability insurance that may not pay out, or if it does, not for very long.

Employer-provided group Plans contain multiple provisions adverse to claimants and benefits should NEVER be relied upon; DI own occupation policies are also denied for unjust reasons. In addition, companies such as Unum, Prudential, CIGNA and Aetna continue to risk manage claims paid long-term sometimes for 10-20 years.

Insurance agents will never tell you that in most cases, disability insurance claims are paid to maximum duration less than 30% of the time. Unfortunately, insurance agents encourage employers and individuals to buy disability insurance they may or may not know won’t pay out if needed.

The truth is, private disability insurance should never be regarded as a permanent or sole source of financial income in any circumstance. Consider. What would YOU do if your insurer notified you today that your claim was denied? Do you have an alternative Plan B in place to cover expenses? Are you depending on your disability insurance to provide continuing financial support? What if it doesn’t? Turn to an attorney? Really?

Unlike the United Kingdom and most of the European Economic Community, the United States does not provide federally funded welfare programs to its citizens. Social Security is the only entitlement available to workers who, along with their employers pay for it. Although the US government often makes us feel SSI, SSDI, and SSR are gifts, they really aren’t. We pay for these benefits.

Instead, individuals are forced to depend on profit motivated corporations that instead of assuming the risk of disability, transfer their risk back to insureds who risk getting paid at all. Why  in the world would any reasonable person conclude that group or DI insurance is a guarantee of benefits to maximum duration? It doesn’t make sense. A good read of the polices or Plans themselves should tell most workers that the coverage is not to be relied upon.

I am really sad for those who contact me, like Mr. T., whose only option after the Prudential denial is to contact human services in his area to find out what benefits the State of Connecticut could offer him. Other individuals have had to live in their cars, on the street, with family, giving up prescribed medications and often access to health care. Often times SSDI exceeds poverty level state income requirements eliminating Medicaid, food stamps, and rent assistance to those who need the services.

Although Lindanee’s blog is not intended to scare anyone, it does intend to INFORM. And, I’d like to be very clear about the fact that neither employer group Plans nor DI insurance is ever a guarantee of payment. Since corporations are both reviewers and payers of claims there will always be a conflict of interest of profit motivation to NOT PAY CLAIMS RATHER THAN PAY THEM. Fiduciary duty and “good faith and fair dealing” went out the window a long time ago.

Unfair denials, although often classified as an ERISA problems, also affect the DI professionals who bought the “better than sliced bread” own occupation policies. Insurers sold own occupation polices convinced that highly paid professionals would never file claims for secondary gain, and they were wrong. Of course DI insurers have strategies to prevent them from assuming uncontrolled liability that in the past nearly caused the DI market to file for bankruptcy.

Private disability insurance is NOT a product that can be relied upon to pay you indefinitely and those who put all their eggs in this one basket could suddenly find themselves without financial support. Once disability claims are denied, the only option is to pay attorneys up to 45% of future benefits to age 65 often bringing monthly benefits to less than 35% of pre-disability earnings – an amount no one could live on either.

The best option for anyone covered by these products is to attempt to provide the best claims management they can in order to AVOID denials in the first place. Once claims are denied, attorneys are either unreachable, or part of the financial problem, not the solution.

Lindanee’s blog receives over 800 reads on an average day. Please, those of you who have access to the blog and can read the over 1,500 posted articles here, understand that there are thousands of American workers denied benefits, medication, and health care each day.

Private disability insurance is NOT a dependable product and I’m asking all of you to think about what YOU would do if your benefits were suddenly denied this week. I’m not trying to scare you, but I am trying to provide you with the limitations of disability insurance products. IT IS  UNWISE TO DEPEND ON THE INCOME FROM DISABILITY INSURANCE LONG-TERM. You may have been lucky up to this point, but future benefits are never guaranteed.

Thousands of people in this country are dealing with unfair claim denials today; I only hear from a few of them.

I do care, and I do listen.

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