ResponsibilityThere’s been some question raised recently about just “who is responsible at Unum Group” for the “bad faith” claims process and unjustified denials. Well, let’s take a snapshot of what we know about Unum’s claims process and see if we can pinpoint responsibility.

 The CEO and Senior Executive Officers sign responsibility statements as part of Unum Group’s financial statements. In brief, the CEO and/or Senior VP’s sign a short statement that they are responsible for making sure the financial statements were prepared in accordance with generally accepted accounting principles, and that in general, they can account for what the numbers mean. This alludes to the fact that if Unum, as a company, was under reserved the top brass would know about it.

An oversimplification of corporate responsibility directs that if the corporation does anything to “cook the books”, the CEO could be held responsible. Unum’s CEO also certifies he knows what went into the making of those figures. Is the Unum CEO responsible for the over all financial reporting of Unum Group?  You better believe it, even though Unum’s CEO positions himself an arm’s length away from actual claims practices and doesn’t get involved in complaints.

So, who can we blame? As an employee I once sent an email note to Tim Arnold, the then Vice President of Claims, and basically told him “you either are not aware of the poor claims process, or if you are aware, are covering it up, or you have lost control of the claims process.” In hindsight it appears Tim Arnold was aware of the poor claims process, but had lost control of it all together.

Either way, as Vice President of Claims Mr. Arnold was in a position along with Ralph Mohney to develop the claims process into a system of fair review, or as it turned out, to an unfair one according to multi-state settlement commissioners, Georgia and the state of California.

Although my experiences with Tim Arnold indicated he was generally fair regarding claims, he did terminate managers and other staff who disagreed with him, or failed to meet projected targets. Although there was no question of Arnold’s being a “good ol’ boy” cohort of Harold Chandler, the claims process at Unum degraded into a big mess at the time.

Therefore, any Vice President involved in the claims process at Unum Group has the authority to devise and implement strategy within the claims process itself. Claims Vice Presidents attend Multi Disciplinary Roundtables on occasion, and can approve denials for business reasons. Vice Presidents can order Managers, Directors and Claims Handlers to terminate claims, or “step up” review procedures to produce increased denials.

Claim directors and managers set the tone of the claims environment within the workplace at Unum. They can either make it a nice place to work, or the worst hell on earth if claims handlers aren’t living up to their unit quota of claims denials. Claim managers have the accountability to “roll in” Unum’s projected profitability targets and therefore they also have authority to do whatever is necessary to make it happen.

Are claims directors aware of what “bad faith” is? Yes, they are. Do they try to implement the claims process in “good faith?” Not when the “powers that be” demand increased denials in any given financial accounting period and continue to expect managers to roll in unattainable profit targets. The job of a claims director or manager at Unum is an impossible trek toward higher and higher unattainable expectations. As a result, it makes people do what they ordinarily wouldn’t do to keep their jobs.

In my opinion, anytime an executive is in a position to create, implement, and evaluate performance of any process or action THEY ARE RESPONSIBLE for the outcome. At Unum Group this would include any supervisory position above claims handlers who are ultimately the lowest rung of the claims review process and nothing more than glorified administrative assistants.

Also, responsibility reaches to Unum lawyers who attend roundtables and who are a part of Unum’s bad faith not just defenders of it. Unum employs long lists of defense attorneys all over the country who have knowledge of Unum’s criminal actions and defend bad faith. These lawyers are also responsible to the people and should be held accountable for their participation in wrongful denial of disability claims.

Are Unum claims handlers responsible then? Yes, they are, but from a different perspective. Since they do not have the authority to create, implement and devise strategy, their responsibility is limited to that of a moral and ethical one.

Certainly we would all agree that Unum employees should report wrong doing at any time. But, ethics is relative—not everyone has the same moral sense of ethical conduct, nor does every “Joe six pack” have the wherewithal to give up a yearly salary and walk away from bad faith. Most claims handlers at Unum need their jobs and do what they have to do to keep them.

Furthermore,, Unum claims handlers are brainwashed by the company into believing they are doing the right thing particularly when awarded bonuses for doing it. It takes a long time in this type of environment to really understand what is going on and come to a consensus that targeting and denying payable claims is wrong. It takes guts to report wrong doing within this company, since when you do, your personnel file begins to get papered and subsequently you’re escorted to the door by security. Unum does not tolerate dissent, or thinking outside the box.

So, who IS responsible at Unum Group? The answer: EVERYONE IS. The CEO, and VPs certainly are from a legal point of view. And, managers, consultants, customer service reps, and claim specialists are from a moral and ethical perspective.

There are those who look back at Unum Life, UnumProvident and now Unum Group and comment that the company should have gone the route of Enron many years ago. Many of UnumProvident’s management probably should have gone to jail, but alas the company was salvaged; and the same people who created and implemented strategies to deny compensable claims were promoted and are running Unum’s claims process today. A bit scary isn’t it?

When the public takes a look at Unum Group it doesn’t see quality claims management or “good faith and fair dealing.” What it hears about overwhelmingly is Unum’s denial of legitimate payable claims for profit. And, every employee at Unum is responsible for that image.

Therefore, on those days when you’re looking for someone to blame at Unum Group, start at the top and work your way down the chain of command to the claims handler’s conscience. It’s the only conscience you’re going to find in the entire company.

Friday Q & A

Q&AI’m not filing a claim because of Unum’s very poor reputation even though I’m ill. Do you agree?

DCS has always taken the view that claimants who meet the definition of disability written in their policies should file disability claims. Regardless of the reputation of any insurer for bad faith disability companies should be held accountable for the policies they sell, and yes, they have to pay some of them eventually.

At the same time I entirely validate the feelings of those who say, “I just can’t go through all that hassle, accusation, surveillance and scrutiny. I know that it would have detrimental effects on my health.”

Therefore, we recommend to insureds that they thoroughly examine their current financial status, and future security before making any decision NOT file disability claims when they may be eligible to receive benefits. This is a life decision that can only be made by individuals themselves. Keep in mind, though, that NOT filing claims benefits insurers at the expense of those who may need the financial assistance in the future.

Is it against the law for Unum to ask for actual psychotherapy notes?

No, it isn’t against the law as far as I’m aware although to be sure you may want to give an attorney in your state a call to verify. However, from a consultant’s perspective, I am not aware of any disability policy that specifically requires the submission of actual psychotherapy notes in order to be paid benefits. My impression is, that most therapists won’t release notes anyway with the statement, “this office does not release actual psychotherapy notes to any outside third-party.”

Having said this, in my experience companies such as Prudential, CIGNA and Aetna (perhaps others) deny mental health claims for failure to submit actual psychotherapy notes punishing insureds for the policies of their therapists. Prudential denies claims for mental health whether psychotherapy notes are submitted or not.

You may recall Prudential uses RNs to review records and if certain aspects of mental health disability are omitted from the notes by therapists, i.e. comments about “affect”, GAF or WHO DAS scores, etc., unknowledgeable RNs recommend denial. It sometimes appears that claimants get caught in a “Catch 22″ position of “denial if I submit” and “denial if I don’t.”

Submission of actual psychotherapy notes poses two problems. First, therapy notes opens up a door to “snatching” by insurers who look for favorable mentions for them at the expense of all else written in the note. And second, patients who know patient notes will wind up on the insurance company’s desk often do not share or confide with their therapists the way they should as it negates the benefits of therapy.

Why does Unum make such a big deal about “occupation performed in the national economy”? Shouldn’t it be the material and substantial duties of my job?

One of the big revelations about group LTD is that these policies do not insure claimants’ jobs, but only their occupations. Occupational descriptions are contained in the Dictionary of Occupational Titles published by the U.S. Department of Labor. As far as I’m aware the last revision was in 1991 so the list maintained  by the DOL is quite out of date I’m sure.

In any event, insurers of group LTD have been permitted to include definitions of occupations rather than insuring actual jobs performed. Of course, it is to their advantage to do so since “occupational descriptions” are more broad and rarely contain specific guidelines for every job in existence. Most jobs are grouped together into general categories and the insurance industry chooses the “occupation” most closely related to specific jobs.

The example I like to use is the Rite Aid Manager who went out on disability due to chronic back issues. Although his “job” required him to lift heavy boxes, stock shelves, and move store fixtures around, the occupation of Store Manger according to the DOT is listed as sedentary. At the change in definition after 24 months Unum cited the DOT occupation as Store Manager (sedentary) and located alternative gainful jobs even though the claimant will never be able to lift heavy objects again.

Of course it’s obvious why LTD insurers use “occupation” rather than “job” descriptions. DOT occupational descriptions often do not take traveling, extensive walking or lifting into consideration. Another example would be that of a Paralegal Secretary required to carry around heavy files all day long. According to the DOT the “occupation of Paralegal” is listed as sedentary with minimal lifting and carrying requirements.

Group LTD claimants should review their policies carefully for the provision that says, “Occupation will be defined as it is in the national economy.” This means the policy does NOT insure the actual job, but only how its is generally performed in the national economy. This is why all group LTD insurance companies make a “big deal” over the distinction between jobs and occupations.

(Please note, DI own occupation policies actually insure jobs performed by insureds, not occupations – another benefit of Individual Disability Income Replacement policies.)

TargetingAs a Unum insured, have you ever felt as though you were living with an eternal “claim target” patch on your back? It’s been my experience that Unum in particular continues to have internal strategies to deny claims that should be paid. You may recall in previous posts that it has always been my opinion that it is impossible for Unum to manage the claims process fairly without its deceptive practices and still make a profit.

“Targeting”, although criticized by state regulators, may still be a part of Unum’s strategy to maximize profits. The objective of “targeting” claims, always was and will continue to be to deny legitimate payable claims using a process of review that creates “the illusion of credibility.” It’s actually a very clever strategy design and insureds should understand what bull’s-eyes are internally created to deny claims. In fact, in my opinion the bullseye replaced Unum’s old red thermometer on the wall.

Although it is unclear exactly what Unum’s target procedures are today, it IS clear from reading Navilink notes and speaking with former employees that certain activities may still be taking place. Below is a list of most of Unum’s claim target activities, past and present.

Planning the Denial

From the moment a new claim comes through Unum’s door, claims handlers construct a deliberate plan of “next steps” leading to probable “claim resolutions.” Claims handlers actually decide at the time of the first review whether the claim is likely to be paid or denied and when. Once it is decided that certain claims are to be denied, the “Primary Plan Direction” then becomes a series of referrals to obtain information. Thus, the “stacking of the deck” begins.

In the past, Unum used various aids to target claims including “ERDs”, or Expected Resolutions Dates, that limit the time “expected” to “resolve” (deny) claims. For example, a claims handler might look up on Medical Advisor that the recovery date for a broken leg is 12 weeks and set the ERD for 12 weeks in the future. Claims managers expected their claims representatives to “pull off” claim terminations at the end of the 12 weeks, making it easier for managers to project reductions in financial reserves (profit).

Although it is suspected the good ol’ boys from Chattanooga actually integrated ERDs into the payment system (once an ERD was entered on BAS the financial reserve was reduced, profitability added), I doubt that situation exists today, there is some evidence from Unum claim files that ERDs are assigned as expected termination dates in the future.

Therefore, before any additional investigation of the claim takes place, Unum’s claims handlers have already placed a “target” resolution of some kind in the claim file toward which all activities will move until enough proof is obtained to deny the claim outright.

Targeting Specific Occupations

As previously indicated Unum’s strategy design provides enough information to track which occupations are easiest to deny. In 2002 Unum’s management decided they had paid long enough on 9/11 victim claims and began “target projects” to review all victim claims and deny as many as possible. I know this because I was charged with exactly that objective.

Those who were injured or affected by the 9/11 tragedy were typically Wall Street Analysts, Morgan Stanley and Mercantile employees with extremely high benefit amounts. Unum’s “target” strategy was to compel claims handlers to “present” all claims at roundtable so that management could decide not only which claims were to be denied, but when. Most mental and nervous 9/11 claims were denied at that time.

Interestingly, it doesn’t take a tragedy for Unum to use the same targeting methodology identifying vulnerable “occupations” that can be challenged. Typically, Registered Nurses, LPNs, and Dental Hygienists (most with group ERISA changes in definition at 24 months) are likely easy denial targets because their job descriptions often describe “be all, to all” material and substantial duties. In Unum’s opinion, and ER nurse can also be a school nurse or teach nursing courses.

Finally, addicted anesthesiologists, or nurse anesthesiologists have also been Unum targets with denials alleging opiate addicted physicians can re-enter the surgical arena without difficulty. This one is particularly egregious since it places not only the physicians but patients at risk.

Targeting Specific Impairments

Top ten of most frequently targeted disability claims are: Fibromyalgia, Chronic Fatigue Syndrome, Chronic Pain, Lyme Disease, failed Cervical or Back Surgeries, HIV/AIDS, early Multiple Sclerosis, Depression, Anxiety, and PTSD and Migraines. This list is not exclusive to Unum but I find many other insurers are reluctant to pay for certain claims. Secondary non-compensable impairments include Sjogren’s, TMJ, concussion syndrome, connective tissue disease, and POTS.

Improvements in pharmaceutical treatments for HIV have also encouraged Unum’s medical reviewers to allege HIV/AIDS infected insureds can return to work despite a long list of continued symptoms not alleviated by medications that improve T-cell counts. Therefore, over the last several years there is some indication that Unum, like the 9/11 victims, is conducting projects to eliminate as many HIV claims as possible.

Extended Duration Unit Claims Have Become Targets

Years ago, Unum’s Central Benefit Administration, risk managed all claims awarded SSDI hoping to deny them. But, they didn’t continue to touch PTD claims (Permanently and Totally Disabled) nearly at all. In the Unum Life claims process there actually was a time when claims meeting certain criteria were “put to bed.” Today, there is no department of “retired status” for Unum insureds and claimants.

Unum continues to target claims awarded SSDI, and those that have been paid long-term, sometimes for 10, 15, or even 20 years. Unum’s focus obviously changed from “we accept liability to duration” to “any claim is fair game.” Insureds and claimants need to realize that there is no claim “safety zone” and as long as Unum is paying claims the potential for denial will always exist. In recent times Unum denied claims of insureds in their 60’s just prior to maximum duration.

Red Flags Become Target Claims

Anytime insureds and claimants say or do the wrong things, a “red flag” is created causing claims to receive a “lion’s share” of risk management activity. This is yet another reason why insureds and claimants might want to request all communications in writing. A mere mention of occasional “babysitting for grandchildren”, or, vacation pictures on a Facebook page etc. creates internal “red flags” insureds may never get out from under. Unum claims reps are trained to “listen with denial focus” and can pick up on any mere mention of anything that can be interpreted as suspicious.

For example, last year Unum’s Internet snoop dogs picked up on a corporate record somewhere listing an insured (actually the spouse of the owner) as Secretary to a Corporation owned by her husband. Unum latched so heavily onto this one fact accusing the insured of unreported income that the insured eventually became exhausted and withdrew her claim. A red flag was created by inaccurate Internet information and Unum never let go.

Claimants need to do themselves a favor here and request all communications in writing; you may need the paper trail in the future.

Although the above discussion is just the top of the iceberg, “targeting” disability claims denies insureds the right to fair, objective and fiduciary review based on the unique circumstances of each claim. Although all insureds should be entitled to a complete investigation of claim, Unum slants that process in their favor by determining from the onset which direction the claim will be managed toward.

Is this fair? Of course not. State regulators have cited Unum’s “targeting” as a major concern, but the company yawns with a “ho-hum”, pays the fine and goes on doing what it has always done – targeting claims for profit.

One out of 10 attorneys I speak to are now claiming Unum has cleaned up it’s act and are no worse than any other disability insurer. I have to chuckle to myself when I hear this: “Does this mean Unum has gotten better, or that other insurers have gotten worse?”

Still, it’s important for Unum insureds and claimants to know why the Unum claim process works the way it does and how their claims are reviewed.

I still remember the Facebook comment made by one of Unum’s managers on his page, “Claimants are like slinkys; they aren’t worth anything, but you still like to see one tumble-down the stairs every now and then.”

If this is how Unum’s managers view their customers I don’t think insureds should expect too much in the “good faith and fair dealing” department.

Man crying2After working as a former Unum employee and consultant in private practice for nearly 22 years, it is impossible to ignore “the big picture” of how filing a disability claim makes people “feel.” Years ago Unum management required everyone to attend a week-long seminar that essentially taught employees how to eliminate “feelings” from the workplace.

Afterward, employees were criticized for saying, “I feel….”, but in the end the seminar was a waste of money. In the disability business “feelings” are, or should be a priority focus in the disability claims process. After all, feelings are what make us human.

From insureds’ perspectives filing disability claims involves six basic reactions I’ve been able to identify over and over again.

Here they are:

  • Overwhelmed/Scared
  • Intimidation/Stressed Out
  • Compliance
  • Anger
  • Fear/Helplessness
  • Managing Smarter/Getting help

Most disabled persons are completely overwhelmed when packets of application forms arrive. Not only are they worried and involved in managing their health, but now insurers insist on a preponderance of medical, occupational, and financial information that is nearly impossible to provide quickly in order to receive much-needed benefits in a timely way. Some insurers have application packets of 25 pages or more (Sun Life), the complexity of which is very difficult to maneuver.

Although insureds manage to “fill out” all of the forms the process of filing a claim is frustrating in and of itself. The first negative realization of filing for disability is that “benefits are not swiftly paid” and there is usually a delay from last paycheck to first benefit.

In addition, interview calls from insurers begin to happen causing insureds to wonder, “Did I say the right thing?”; “Did I give out too much information about my family?” Frequent telephone calls often cause insureds and claimants to be scared and mistrustful of the process.

By this time, most insureds have obtained enough information from the Internet to create stress and panic. Not realizing that everyone’s claim situation is different,  negativity jumps off the computer screen directly into claims situations that are entirely different. Fearful and assured that no benefits will be forthcoming, claimants are often intimidated by claims reps who use the complexity of the system to get what they want – namely more and more information that can be used adversely to deny claims.

Unfortunately, it’s at this point that insureds spend hours on the phone talking to reps trying to convince them their claims are credible. “If I could work, I would work”; “Perhaps I can go back to work in six months?”; “I miss working, I really do.” Once claims reps realize you are a “talker”, phone calls increase to as much as once a day.

Overwhelmed, scared, intimidated and stressed out with the process so far, most insureds become compliant and will do anything the insurance company suggests in anticipation of receiving benefits to pay the bills. Adaptation of a complaint attitude is recklessly providing and saying anything that will get a claim paid regardless of whether it’s in the policy or not! Most insureds think at this point, “If I just say or do the right thing, my claim will be paid.” Or, “If I provide the insurance company with everything and answer all of its questions my claim will get paid.”

However, it doesn’t take very long for insureds to figure out that despite “providing everything, saying all the right things, and being compliant” claims still aren’t getting paid. It’s at this point insureds become angry and often express their anger in multi-page letters sent to insurers again attempting to explain their disabilities and defend rights to receive benefits. Many insureds tell me at this point, “I don’t have to worry because I’m not doing anything wrong. They can conduct surveillance anytime; and they won’t see me doing anything wrong.”

(I should note also that unfortunately some insureds and claimants have gone this far in the process without actually obtaining copies of their policies to clearly understand what their rights and obligations are. Going in to the disability claim process blind without a policy is the worst thing any insured can do.)

Insureds tell us, “How can they do that? My doctors have said over and over again I’m disabled.”; “I want this insurance company to pay me every single penny it owes me!”; “I’m not going to let them get away with this!”; and, rant, rant, rant. “I’m taking them to court and I don’t care how much it costs me.”

Unfortunately, anger doesn’t get anyone anywhere and once insureds begin to understand that “insurance companies never admit fault at anything, and nothing they do or say will change the evaluation of their claim, fear and helplessness becomes an overwhelming emotion that is both destructive to the individual as well as to their claim. Fear is a very powerful emotion and it can make people do things they ordinarily wouldn’t do or say.

If benefits have been paid, it’s at this point that insureds wait nervously for checks to arrive complete with palpitations, anxiousness and worry. “My check is late! What am I going to do now?” “Did they cut me off?”

Many times, going through the process this far, with all of the above “feelings” and emotions, a secondary disability of managing a disability claim appears with identifiable symptoms of its own. Insureds realize that despite medical treatment they aren’t getting any better because of the emotions and stress connected to the disability claim. This appears to be insureds’ “rock bottom” – the realization that despite all that’s transpired in the process, they are worse off health wise and have no idea where to go from here.

In truth, the disillusionment with the claims process is really a let down. Most insureds do not want to remain unhealthy and look to their disability claims as  “financial safe havens” so that they can focus on health issues and eventually return to the workplace. What insurers may not realize is that the corruption and complexity of the claims process actually causes insureds and claimants to remain on claim longer than needed, or permanently.

Finally, it’s at this point that insureds begin to realize the importance of knowledge and information; policies are obtained and read; insureds may seek help from those who are “in the know”; and most importantly insureds begin to manage smarter.

“No, I don’t have to do everything my insurance company says! I’ve checked my policy and I don’t have to do that!” “I blew the cover of that surveillance guy and he went away!” “I’m providing my insurance company with information required in the “proof of claim” provision in my policy.” “I’ve notified my insurance company I want all future correspondence in writing so I can create my own paper trail.” “My doctor and I have decided a plan of action in dealing with calls and requests from insurers!”

What a difference!

Despite the progression of feelings and emotions from all of the above mentioned, insureds and claimants eventually arrive at “rock bottom” and realize they may need help through the maze of confusing paperwork, deception and vexatious processing.

However, getting help is not my main message here necessarily – it’s realizing that filing disability claims is not only a tangible paper conundrum of chaos and complexity, but also a process of “feelings”, emotions and reactions that contribute TO disability and ill-health, and certainly should not be regarded as the “safety zone” most people think it is. Most people will work through the above cycle of emotion, eventually figuring out “a smarter plan.”

My hope is that insureds and claimants reading this post will be comforted in knowing that the feelings and reactions they experience are not unique to them, but quite common among all those who file disability claims.

Some of you may even be stuck somewhere in the cycle as described above. If so, reading this post should encourage you to skip right to the bottom of the emotional process and manage your claim in a smarter way. With or without expert help I’m sure you can do it!

NCDI_Logo_colorInformation is still coming in from claimants indicating Unum may be sharing claim information with the Social Security Administration. One of my clients recently provided me with a copy of an 8 page questionnaire from SSA asking about her return to work activities when there were none. This letter was received shortly after a Unum update took place and completely by surprise.

Those of you who are receiving out-of-the-blue requests for updated information from SSA should sit up and pay attention. If you allowed Unum to obtain a copy of your SSDI file, including Form-831 then Unum is most likely feeding information back to the DDS who made your SSDI approval decision.

Although it’s unclear exactly what connection or involvement Unum has with SSA, letters received by claimants from SSA and Unum seem to indicate a connection of “risk management” in a U.S. entitlement program paid for by American workers and their employers. Given the fact that Unum has a conflict of interest in looking to NOT pay claims, decisions made by SSA should be made in accordance with different standards in accordance with federal law, not on the say-so of Unum, or any other American corporation.

Claimants may recall at the time of their initial approvals SSA may have cited directly in the approval letter if “updates” will be required and when. Claimants receiving SSA letters today were not originally set up with time frames for review and there were no mentions of update reviews in their initial approval letters. New requests from SSA occur shortly after a Unum SSDI file receipt or claim denial.

It’s also important for claimants to know that Unum’s denial letters have been informing claimants that although they received copies of SSDI files, SSA’s decisions have been ignored because Unum was able to obtain more recent information indicating claimants may no longer be entitled to SSDI or Unum benefits. This is consistent with Unum’s presentations before the House Ways and Means Committee offering “to assist SSA with their fraud problem…..because Unum is an expert in identifying claims that should not be paid.” (Or, denying more claims than any other insurer for profit?)

Unum claims reps who sell the company’s requests for SSDI files as, “we want to make sure your claim gets every possible consideration” are not being truthful as to why they want the file. Unum looks for mental and nervous diagnosis codes and other information that could be used to support terminations of claims.

This is happening after Unum threatens claimants under penalty of estimate if they don’t apply for SSDI. Therefore, on the one hand Unum forces all group LTD claimants to apply for benefits, collects overpayments once awarded, requests SSDI files, and denies claims with the statement, “since we were able to obtain more recent information, we are not required to consider the SSDI decision.” This may be the most egregious estoppel situation allowed to exist to benefit the insurance industry.

Finally, having used SSDI awards for its own benefit, Unum may be forwarding information back to SSA that could result in the taking away of SSDI from families who need the income. Readers need to consider what will happen when Unum denies LTD benefits followed by denials of Primary and Secondary SSDI on Unum’s say-so. Claimants will have no other alternative but to find work somewhere, or starve on the streets. Is this what you want to happen?

I’m wondering by what Congressional authority Unum is allowed to do this. Unum’s pattern of allegedly obtaining SSA permission to ignore SSA-3288 and replace it with CL-1155 that included additional authority and permission to obtain SSA Form 831.

This consultant has requested copies of all authorities, exclusions and communications under the Freedom of Information Act between SSA and Unum. Although I didn’t expect to receive a response, on Saturday I received a letter from SSA informing me it is looking for the information I requested. We’ll see whether I really get the information or not.

NCDI, the National Coalition of Disability Insureds was created for the purpose of public outcry for issues such as these. American claimants and insureds could prove to be a powerful voice if linked to a common cause. If you do not want to risk SSDI benefits I’m suggesting that you write letters to the House Ways and Means Committee and Senate Finance Committee asking that Unum not be allowed to deliberately interfere with SSA’s decisions. You could be a big help in persuading Congress to tell Unum “to get lost.”

Given Unum’s “criminal organization” and “bad faith” conduct market examinations it isn’t unreasonable to expect our leaders to eliminate Unum as any significant advisor of a federal agency. Moreover, I know some readers do not like it when I mention Unum’s interference in the UK; still, what happened in Great Britain could very well happen here.

The American people could make a difference here and I strongly suggest that claimants not take the risk of losing SSDI when Unum denies claims. Rethink decisions to allow Unum to obtain SSDI files, and write letters to Congress today. A federal entitlement paid for by the American people should not be run by a private for-profit corporation with a conflict of interest to deny claims.

For security reasons it is preferable to fax your letters to both Committees.

U.S. House Ways and Means Committee, Chairman Paul Ryan 202-225-2610 Fax

Senate Committee on Finance, The Honorable Ron Wyden 202-224-4515 Fax

And, you may also contact your own Congressional leaders!

Businessman yellingWhile I can certainly understand the level of frustration in dealing with disability insurers there are times when insureds cross the line and refuse to cooperate with the efforts of insurers to fully investigate claims. This was brought home to me very quickly this week, when despite efforts to assist with a new client it became clear he just wasn’t going to cooperate.

In fact, the claims representative said to me, “Now, I understand, Linda. I’ve learned more from you in the last several minutes than I’ve been able to obtain from the insured in several months.” An uncooperative insured does nothing but delay payment and create administrative nightmares on both sides of the fence.

Insureds and claimants have contractual responsibilities to provide information when asked to do so, and to cooperate with the insureds efforts to investigate continuing eligibility for benefits. On occasion, insureds become so obstinate they actually come to believe they have control over certain aspects of their claim and, in particular, the IME process when they really don’t.

For example, most disability contracts contain provisions regarding Independent Medical Evaluations. Although insureds can ask for certain accommodations, the IME process is not something they have control over. Simply put, insureds who won’t go to scheduled IMEs lose benefits. In addition, those insureds who are uncooperative as to scheduling, or who consistently fail to show up on the scheduled dates are deliberately planning their own claim demise. 

In addition, insureds have no control over who the IME physician is since insurers are not required to consider alternatives just because insureds don’t want to meet with certain individuals, or in preferred locations. Insureds and claimants are not allowed to contact IME physicians in any way since phone, or in person contact may invalidate the IME before it even happens. Insurers could choose to reschedule an IME when insureds place calls directly to IME physicians or their offices.

Continued failure to show up for scheduled IMEs will almost always result in a claim denial. Of course, I’m not talking about logical objections to IMEs such as traveling long distances, or showing up when the IME is suddenly cancelled. These occurrences are justified complaints about the process. I’m specifically referring to insureds who do everything they can to “obstruct” the investigation of their own claims while at the same time expecting insurers to uphold their obligations to pay.

A particular client this week attempted to convince me that “attorneys he’s spoken to” assured him he didn’t have to attend an IME. Although I generally don’t support attorneys all that much on this blog, I am absolutely certain no attorney would advise someone to violate his contractual obligations under any insurance policy. Disability policies are contracts and each party to the contract is expected to provide all duties and accountability under the terms of the policy. This includes both insureds and insurers.

When insureds mirror the behavior of “the bad guys” they lose. Believe it or not, it is possible to work with insurers in a state of cooperation to achieve a desired result.

This is the type of assistance DCS provides to insureds and claimants who approach us to come on board as clients.

Unfortunately, I do not continue to work with those who have become so angry and obstinate that they “obstruct” their own claims and literally become “the bad guys.” I really feel awful for the people who fall into this trap because they eventually throw away their much-needed benefits for no reason.

IME2Disability insurers depend on state approved contractual provisions in disability policies allowing them to require insureds and claimants to submit to so-called Independent Medical Evaluations. The word “Independent” does not imply “fair or objective review” but instead makes reference to the fact that insureds have not consulted with IME physicians in the past. In reality, IMEs are no more than attempts to obtain written documentation supporting the insurance industry’s agenda to deny more claims than it pays.

Although most insureds and claimants view IMEs as “Oh boy, now I’ve had it!”, they are not entirely defenseless in the process. As always it is important for insureds and claimants to place rebuttal documentation into the file that is favorable to them. See below.

IME physicians have a bias in favor of insurers. Given current billing and medical practice procedures it is often more lucrative for physicians to provide insurers with IME reports rather than provide patient care in practice or as a member of a physician facility. Insurance IMEs are a million dollar a year industry to physicians “who can’t practice, but still want to make money.” Insurers who contract with physicians generally get exactly what they pay for – written reports favoring the already determined agenda to deny legitimate payable claims.

I think we should be truthful here and say that IME physicians wouldn’t be popular for very long if they rendered reports in favor of insureds. Unum’s IME Network, for example, maintains lists of physicians who submit reports in a timely fashion and in its favor. Therefore, it is reasonable to presume that IME physicians know where the money is, and render reports in favor the insurance company signing their checks.

Also, it’s always been interesting to me that insurers allege insureds are pursuing disability claims for financial gain by forcing them to submit to IMEs conducted by physicians specifically in business for financial gain. If the evaluating physician has a large IME practice it’s hard for him to dispute bias when at the same time charging between $1,200-$5,000 per exam. Insureds need to search for the IME financial gain bias and make sure the information is added to the file.

Investigate IME physicians and add to the file.

Insureds can conduct their own investigations of examining IME physicians and find out important information about him/her. Insureds and their representatives can look for prior malpractice actions, medical board or license problems, and also disability claims filed by IME physicians themselves. Have the IME physicians worked for insurance companies in the past? Are they retired now, but still writing IME reports for insurers?

One of the best sources of information about IME physicians is treating physicians. Most reputable physicians take a dim view of others in their field who sell ethics and “board certified credentials” to the highest insurance bidder. Insureds should also ask their treating physicians if they know of an assigned IME physician and what his reputation is.

IME Networks may also hire predominately foreign physicians from India, Philippines, and Thailand and provide them with rented or temporary facilities to conduct IMEs. One DCS client was sent to an IME in Boston directly across from a trucking “red-light district.” It actually scared our female client quite a bit.

Investigating IME physicians and adding the information to the record is an absolute must for insureds who have been requested to appear for an IME.

The IME doctor is not qualified to render opinions concerning your claimed disability.

Insureds should realize that IMEs are NOT accurate assessments of anyone’s medical condition, nor should insureds ask medical questions or seek recommendations from IME physicians. Without a treatment history of medical consultation with you, IME physicians are likely to do more harm than good.

In addition, IME physicians rarely see patients and often do not keep up with new information on the practice of medicine. Insurers often consider PM&R (Physical Medicine and Rehabilitation) physicians as qualified to render opinions on all impairments when in fact these physicians are generally “sports” doctors. If you break your leg skiing, or have tennis elbow, these physicians can usually help you – FMS and heart attack not so much.

Since insurers are reluctant to pay for real qualified physicians who can evaluate your claimed disability, IME examinations are merely an arm of the insurance company supporting denials. Remember, there is no real intent to provide anyone with an accurate assessment of impairment or disability.

IME reports are very good keys as to whether physicians are savvy to the “own occupation” lingo or not. Once an IME physician makes the statement, “there is no objective evidence to support disability”, or “no restrictions and limitations are found” it’s pretty clear he’s been around the block a couple of times on the IME defense circuit.

IME physicians will ignore evidence favorable to insureds such as X-rays, MRIs, CT scans and attending physician comments. Insureds often report to DCS that information provided to IME physicians at the time of the exam is left on a table with the comment, “I already have a file from the insurance company”, or, “I can’t review that.”

The truth is, insurers rarely send IME physicians a complete file, but only a selected amount of paperwork including internal reviews that already support denial. Many times Unum provided IME physicians with the amount of pre-disability salary to make sure evaluators understood the financial stake Unum had to deny the claim.

In the end, IME physicians review what is sent to them by the insurer and generally ignore all else. Insureds should always provide IME physicians with updated medical information from treating physicians.

Find out what the IME physician does with your medical records before you leave the office.

Most insureds don’t even think about what happens to their medical records after the IME. Some physicians outsource a shredding company who shreds the records, but what if your file was provided in electronic format? What happens to it? If it’s a paper file does it sit in an office somewhere subject to review by anyone? DCS recommends that all insureds ask the IME physician about the disposal of paper or electronic medical records before leaving the office.

Independent Medical Evaluations are what they are – insurance defense mechanisms to obtain what appears to be credible information documenting insureds can work and should not be receiving disability benefits.

IMEs are just one more link in the chain of “stacking the deck” to deny claims. Insureds just never seem to catch a break from the corrupt reviews and decisions made by disability insurers for profitability sake.


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