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attorney generalMaine Attorney General Janet Mills is apparently still challenging anyone who gives (or not gives) legal advice outside of her office. Maine attorneys have much to fear when in despot-like manner she tells attorneys in the governor’s office they can’t give legal advice.

While Maine citizens are criticizing Governor LePage for making inappropriate comments regarding shooting drug dealers and bringing back guillotines, Maine citizens have a greater fear from an Attorney General with control issues about “holding oneself out as an attorney” even when they ARE attorneys  employed in the Governor’s office.

Special Counsel to the Governor, Cynthia Montgomery, has an excellent point when she responds, “We don’t trust you!” As Attorney General, Janet Mills, turned down requests by Governor LePage to represent the state, and now she doesn’t want any other attorney to represent the governor either even if they work in the executive branch. I agree with Ms. Montgomery – I don’t trust Janet Mills either!

This Attorney General and her minion assistants seem to be controlled by special interests. Not long ago the AG brought charges against a man yelling too loudly at a protest of Planned Parenthood. In her acceptance speech Janet Mills promised to rid Maine of “the terrible habit of smoking?”

The Attorney General recently permitted Unum to set policy on insurance matters relating to third-party non-attorneys. Maine’s AG has always had a special relationship to Unum, but the two obvious bedfellows are not protecting Maine consumers by giving in to Unum’s every whim.

Consultants providing disability reviews and advice to the insurance industry such as Unum Group, Prudential and Aetna aren’t required to be licensed. (Look up PDA on the Internet – ex-Unum executives aren’t licensed. Why?)

Therefore, one can only presume the Maine AG does not apply its licensing laws fairly to all citizens. It still makes me nervous to think that the highest law enforcement official in the state has no checks and balances. Janet Mills and her assistants have unlimited power and there is absolutely no one who can reign her in.

In my mind, Janet Mills can’t both refuse to represent LePage and then criticize the Governor for getting legal advice from other attorneys. Is Janet Mills and her assistants the only lawyers who are allowed to practice law in the state?

If I were a lawyer in Maine I’d pack now for California, or maybe Washington State or Oregon where they will be appreciated and actually be allowed to, “hold themselves out to be the attorneys they really are.”

In my opinion, Maine’s  attorney general is a narcissist with control issues and should be impeached before she really does some damage.

Please read the following article:

http://www.pressherald.com/2016/01/24/state-a-g-says-lepage-violates-state-law-with-legal-advisers/

http://topclassactions.com/lawsuit-settlements/lawsuit-news/306357-former-medical-assistant-sues-unum-for-bad-faith-insurance/http://topclassactions.com/lawsuit-settlements/lawsuit-news/306357-former-medical-assistant-sues-unum-for-bad-faith-insurance/

Audio Recording 2Today, one of my clients sent me a You Tube write-up from the attorneys who advertise there about how they specifically requested that a client IME be videotaped. Unum pulled a fast one and told the firm it would provide the videotape, but then told the investigator to leave the lens cap on and only audio record the session.

Unum has been engaging in this type of fraud for many years, and in fact, DCS, Inc. has had several dealings in the past with Unum about “lens cap on – lens cap off” issues.

In one particular DCS case several years ago during a psychiatric IME, Unum’s investigator who was allowed to only “audio record” took the lens cap off and videotaped the session, then lied about it later. This is a major violation particularly during a psychiatric IME that was extremely private. Of course, Unum defended the investigator even though the insured took a picture that showed the lens cap not on.

Audio EquipmentIn another DCS case Unum hired someone to audio record the session, but brought this equipment into the room. Why would anyone need a computer screen and all that equipment to “audio record”? In this case the insured became so scared that she ran from the room and insisted that the equipment be taken away.

Fortunately, she brought a witness who was able to take a picture of the equipment set up by Unum’s investigators. Although I’m not a tech expert I’m pretty sure this was over kill for an “audio recording.”

This is not new for Unum, in fact the company has been getting away with this for a while. Unum insists that any audiograph hired by insureds or their counsel can “distort” the recording. What is so egregious about Unum’s behavior is that the company isn’t honest.

To tell the insured that the session is only going to be audiotaped when it is really videotaped is “bad faith”, and at least the You Tube attorneys named it correctly as bad faith. The Tube attorneys have insisted that Unum provide them with an apology letter signed by the CEO, but I hope they don’t wait too long for that to happen.

I had a conversation on the phone today with another well-known ERISA attorney who shared with me that in his opinion Unum is worse now than it has ever been. I agree. When one considers it wasn’t all that long ago that Unum was investigated via a multi-state conduct market examination and found to be unfair, its current conduct is as John Garamendi described it, “unlawful.”

Tube attorneys are just now catching on to what DCS has known about for many years. Unum is not unlike a wayward child – you have to watch them every minute!

Friday Q & A

Q&A3Can I do my own appeal with Unum?

In 2015 Unum went to a great deal of trouble to lobby and influence state law regarding who can submit or defend disability claim appeals (and settlements) mainly because it is in their best interests to do so.

Given my own personal success rate with appeals in the past, it’s obvious to anyone that Unum in particular doesn’t want any expert submitting documentation or proof of claim to the file or Administrative Record that might cause the company to lose a future lawsuit or be compelled to pay the claim.

Other insurers do not care who submits the appeal, they just don’t overturn and pay either, at least not without a fight.

Therefore, it’s a recognizable fact that either insureds or claimants defend themselves on appeal (in which case they rarely win), or retain attorneys to file the appeal for them.

And………….I’m not crying about the decisions to limit appeal representation to attorneys. Here’s why.

Many of you know that I continue to work for several attorneys across the country and in the last few years it has nearly become impossible even for attorneys to overturn claim appeals without a preponderance of additional expert support.

One attorney I work for charges a standard fee of nearly $7,000 for additional resources including an FCE, IME, Psychological IME, Consultant’s Report, Vocational and Rehab Reports and any other expert reports deemed necessary to over turn claims. Even then, insurers are reluctant to re-open financial reserves and prefer to force settlements or take their chances in court.

Once disability claims are denied and closed, it is much harder to submit enough information to the record to force insurers to re-open and pay. Many attorneys I’ve spoken to recently openly admit, “Unum isn’t overturning appeals now.”

Therefore, I continue to emphasize that it is much more proactive to retain experts to advise and assist while claims are still paid to hopefully prevent unnecessary denials. No one should want to do without benefits during a year-long appeal that has less than 20% of success. Even when appeals ARE successful, attorneys walk away with 40% of future benefits to age 65.

So while insureds and claimants have the right to represent themselves on appeal (to the delight of insurers), in a large percentage of cases having an attorney of record isn’t all that helpful either.

The best possible outcome is to prevent claim denials and avoid “appeals” all together. Makes sense to me.

Unum is refusing to speak with my spouse and neighbor on my behalf because I’m too ill to do so. Why?

I was actually wondering when insureds would ask this question. The truth is that Unum sets up what is called a “Chinese Wall” between internal/internal departments and internal/external communication.

A “Chinese wall” is a metaphor for corporate barriers to communication, understanding, or action. It is a barrier of silence and/or secrecy established within the organization to prevent leaks of corporate process and strategy inside the company from reaching anyone on the outside.

Let’s face it. Unum engages in claim targeting, unfair claims practices, “dumbs down” its claims handlers, and sends management to “off-sites to discuss its next steps to plucking insureds.” What accountants typically call, “an arms length transaction” is Unum’s Chinese Wall -the idea that if Unum’s claims strategies and practices can be kept secret, all will be well with profitability.

Medical and executive personnel are cautioned not to discuss bonus amounts received among each other under threat of termination. Non-exempt employees are rarely promoted to exempt positions.

And, Unum openly enforces the “no talking” rules to any outside third-party who is an expert, knowledgeable, questioning, and or qualified as non-attorney representatives.

In addition, nearly every process, department, unit, etc. within Unum is the result of Chinese Walls constructed to protect the company from leaks or accusations of conflict of interest.

It’s unusual for Unum to disallow communication with spouses or neighbors who usually aren’t that informed about the claims process. Normally, Unum’s Chinese Wall is enforced only between qualified non-attorney experts who are capable of getting information into the record that might affect profitability.

Hence communication could be limited to “in writing only”, a concept I’ve always recommended anyway in order to protect the record because of Unum’s unfair claims practices.

There is nothing conducted at Unum that is not hid behind a Chinese Wall of some kind. Keep in mind Unum is also known to act like a child by throwing “hissy” fits about some claims request, letter or practice anyway, particularly when a claims handler or consultant is ticked off.

I should also mention that no other insurance company I know of behaves like this. What’s Unum so protective of? Scared of?

If you were Unum, and were “dumbing down” your claims handlers would YOU want them communicating verbally with a claims expert? Probably not. Basically, anytime information derogatory to Unum could possibly be entered into the record – up goes the Chinese Wall of silence.

DCS has never recommended verbal phone conversations with Unum’s claims handlers. All communications from this company should be in writing anyway.

Kidding meAlthough this is certainly not the first time I’ve heard of Unum investigators making this mistake, it is quickly becoming a business habit of the company.

Unum’s overwhelming excitement to entrap its insureds with useless “I got cha’s” the company seems to be all over the map and are reporting activity on the wrong people.

A recent insured called DCS and reported Unum actually closed her claim as a result of conducting surveillance on the wrong person. When she reported, “It’s not me!” Unum reopened the claim under Reservation of Rights and is now chasing her for voluminous information including an IME.

Clearly, Unum’s personnel is one taco short of a combination plate lately as insureds and claimants continue to report “errors and omissions” that any prudent insurance company should be able to avoid.

It wasn’t all that long ago that one Unum’s rep kept sending “Requests for Taxpayers Tax Returns” (Form 4506) asking for 14 years of returns the IRS no long keeps. The company was informed as many as three times the IRS doesn’t keep tax returns that long before it let go of that red flag.

Conducting surveillance on the wrong person is malpractice. Since Unum did deny Ethel’s claim (not her real name), she could have tried to locate the person Unum DID spy on and provide her with the information from her claim file. No one likes to be spied on particularly someone without a Unum claim.  I wonder how that would have played out?

In my opinion, Unum Group is quickly falling into the “incompetent” category of insurers along with Aetna, CIGNA, The Standard, Reliance Standard and Prudential. Denying someone’s claim because surveillance was conducted on the wrong person is an action Unum should be held accountable for.

We really feel bad for Ethel that she now has to endure the lion’s share of Unum’s risk management harassment for something that wasn’t her fault.

Unum will not let go of the red flags quickly, and one has to wonder what the heck is going on inside Unum……..

Bill of rightsDisability Claimant’s Bill of Rights – 2016

As a direct or indirect party to a disability contract involving insurance coverage for disability or income replacement, you are entitled to generally recognized rights of expectation that the provisions agreed to in the policy contract are adjudicated in a fair, unbiased and equitable manner by disability insurers.

You have the right to full disclosure. As the insured party to a disability contract you have the right to receive and examine all collected data, both paper and electronic, collected by the disability insurer in the process of reviewing your claim for benefits. This includes all administrative and chronological records, conversations, meetings, data base checks, electronic website information, field surveillance, website investigation and Internet searches, and any other data affecting your privacy as an individual. This right exists due to ERISA disclosure rules allowing claimants to obtain copies of their Administrative Record within 30 days of requesting it. These rights should be explained to you in detail in any denial letter you receive.

You have the right to privacy and respect. You have the right to expect medical records and any other private information that reflects upon your credibility, integrity or reputation, to be kept private and communicated with respect and in accordance with HIPAA. You have the right to know what type of information is requested over and above that which is needed in making a fair decision on your claim.

You have the right to know when your claim is reviewed in a public forum (roundtables), and by whom. You also have the right to know the name and title of the claims person who will actually be making decisions about your claim. Quite often, it is not the claims specialists who do this.

You have the right of self-representation. As the owner or certificate holder of the policy or Plan, you have the right to defend your policy or Plan in any manner you find appropriate. This means you may obtain information from the Internet, retain qualified experts to assist you, and communicate your concerns to any insurance company to defend your right to receive all benefits you are entitled to. Insureds and claimants may communicate with insurers over and above any “administrative assistance” retained in defense of their benefits and policy. Self-representation is a right of ownership of a policy, or a certificate holder of an ERISA Plan.

You have the right to control the release and location of your medical records. You have the right know who is requesting medical information about you and have the opportunity to review any information prior to its being released from your doctor’s office. Insureds and claimants should discuss with their physicians how to handle doc-to-doc calls and frequent requests for patient notes from insurers. Information should not be withheld from insurers, but you have the right to know who is requesting your patient notes and how often. You also have the right to obtain your medical records yourself and provide them to insurers.

You have the right to a timely claim decision. You have the right to expect your disability insurer will make every effort to render a claims decision within 45 days (ERISA claims) or that period of time indicated in the policy provisions. You have the right to be notified in writing every 30-45 days as to the reason why your claim decision is delayed. ERISA regulations require the insurance company keep you informed by sending “tolling letters” if the claim decision is not make within the 45-day period. Unresponsiveness is an unfair claims practice, as is deliberately delaying claims decisions with multiple requests for more and more information. All insureds and claimants have the right to timely claim decisions.

You have the right to request all communications in writing. In order to protect the integrity of the record you have the right to request to be free of phone calls from your insurers so that you are allowed the opportunity to think about your responses. This is particularly important to those who are taking pain or opiate medications. Insurance companies keep written records of every activity taken on the claim and insureds and claimants have the right to request all communications in writing to generate diary records of their own.

You have the right to a fair and objective claim review. You have the fiduciary right (ERISA) to expect your disability insurer will make every effort to consider ALL recommendations and opinions given to them by your primary care physicians, consultants, counselors, and any other specialist who is qualified to render an opinion concerning your ability to work. You have the right to expect the disability insurer will consider the experience and qualifications of your doctor as equal or better to those of its own in-house physicians, and to make fair and honest attempts to reconcile professional differences of opinion. All insureds and claimants have a right to expect that claims will not be targeted based on financial reserve values and will be reviewed in accordance with the unique circumstances of each claim.

You have the right to fair representation of facts. As the insured you have the right to a clear understanding as to the party or parties responsible for making the liability decision for your claim. You have the right to know who is authoring communications to you from your insurer, and the first and last names of all claims personnel, consultants, directors, and others who are offering medical or administrative opinions concerning the facts of your claim. You also have the expectation of receiving unbiased medical review and internal medical opinions that inherently will not cause you or others future harm. Insureds and claimants have a right to be told the truth, both verbally and in written communications.

You have the right to ask questions. As an individual outside of the specialty of the insurance industry, or understanding of that industry, you have the right to knowledge, explanation, definition, instruction and full understanding of the provisions of your policy without fear of loss of benefits. You have the right to ask questions concerning your claim as often as is necessary for your understanding of the facts without fear of retaliation, suspicion, or unfair investigation tactics. You also have the right to retain any third-party to assist you and to obtain information from any other resource as you feel is appropriate in defense of your claim.

You have the right to ethical conduct and “good faith and fair dealing.” As an insured you have the right to expect your disability insurer, and its representative employees act in “good faith.” You have the right as an employee or policyholder to expect your insurance company creates and maintains a clearly defined disability claims review process which lends toward the fair, objective and timely, review of all claims submitted as part of its product business. You have the right to expect your insurance company have in place a process that routinely and consistently corrects flaws within the review process; recruits, trains and retains individuals qualified to review disability claims; and provides a forum for independent appeal processes.

You have the right of non-discrimination. All insured have the right to expect their insurance company not discriminate on the basis of benefit amount, self-reported or physical impairment, education, training or experience, occupation, age, sexual orientation, mental and nervous disorder, policyholder, geographical region, claim location, event, physician, claim duration, months of paid benefits, or any other target objective identified by management. You have the right of expectation that your claim will not be targeted by management for denial as a “block of business” due to any of the above. The right of non-discrimination also includes eliminating abuse of targeting and using “credibility issues” as sole cause for denial of claims.

You have the right of appeal. As an insured covered under the Employment Retirement Security Act of 1974 (ERISA) you have the right to a timely independent appeal review of your claim. For non-ERISA individual disability claims, you have the right to report discrepancies to your state authorities and to retain legal counsel, and request “reconsideration” of any denial decision. You also have the right to obtain copies of your Administrative Record or claim file if your claim has been denied; represent yourself or obtain counsel; and expect that all additional supporting documents submitted will be reviewed and considered.

__________________________________________________________________

This “Bill of Rights” was written by Linda Nee, a licensed Disability Claims Consultant. Although there is no law or regulation upholding these rights as an official document, the rights described herein are reasonable and should be expected from any disability insurer with a duty to uphold generally accepted industry standards to review claims objectively, and without bias or financial prejudice.

NCDI_Logo_colorIn 2004, the then New York State Attorney General Eliot Spitzer, New York State Insurance Superintendent, Gregory Serio, and lead regulators of Maine, Massachusetts and Tennessee announced a settlement with UnumProvident and five of its subsidiaries.

The settlement resolved issues surrounding Unum’s exposed unfair claims practices by 60 Minutes and NBC Dateline. Investigations were conducted by the three lead regulators as well as the United States Department of Labor. At the time Eliot Spitzer was also investigating Unum’s payment of contingent commissions and steering and bid-rigging in the insurance industry.

According to Attorney Spitzer, “This settlement sends a strong message to disability insurance companies that improper denials of disability claims will not be tolerated.” He went on to say, “These claim denials involved vulnerable workers – those whose illnesses and injuries reverted them from continuing their employment. I am very pleased that these individuals will have their claim reviewed, and that UnumProvident will not implement the structural reforms necessary to ensure that future claims are handled appropriately?

Although at the time it was estimated that the multi-state settlement would result in expenditures of over $100 million in restitution to policyholders and in structural reforms to improve compliance and monitoring, it’s clear that today (2016) Unum Group continues to engage in unfair claims practices denying more claims than ever.

The multi-state agreement also stipulates that if Unum fails to meet acceptable levels of accuracy in making disability claim determinations it could be fined a penalty of $145 million.

The actual conduct market examination identified several claims handling practices of concern to lead regulators, including:

  • Excessive reliance on in-house medical staff to support the denial, termination, or reduction of benefits;
  • Unfair evaluation and interpretation attending physician or independent medical examiner reports;
  • Failure to evaluate the totality of the claimant’s medical condition; and
  • An inappropriate burden placed on claimants to justify eligibility for benefits.

Regulators also announced that the Unum companies would pay a fine of $15 million and reassess 200,000 claims. If the companies failed to meet the terms of the Plan of Corrective Action set forth in the agreements, a substantial fine of $145 million would be imposed.

In addition to the $15 million fine and reassessment of 200,000 claims, the Unum companies were also required to:

  • Restructure their claim handling procedures to ensure that all future claims are reviewed in a fair and objective manner;
  • Select medical examiners based solely on merit, and ensure that those examiners review all relevant records before reaching a determination;
  • Require personnel making impairment determination to certify the their decisions were based upon a review of all the relevant evidence;
  • Prohibit company personnel from trying to influence the outcome of disability claim appeals;
  • Grant significant weight to findings of disability by the United States Social Security Administration;
  • Improve employee training;
  • Create a new Regulatory Compliance Unit to monitor the companies’ compliance with applicable laws and regulations;
  • Conduct periodic audits of the new claim reassessment process, to ensure compliance with the terms of the settlement; and
  • Appoint three new independent members to the board of Director , add one new independent member to the Audit Committee, and create a new Regulatory Compliance Committee of the Board of Directors.

Also, Section B.3 c(i) of the RSA was amended to include:

“Giving significant weight to an attending physician’s (“AP”) opinion, if the AP is properly licensed and the claimed medical condition falls within the AP’s customary area of practice, unless the AP”s opinion is to well supported by medically acceptable clinical or diagnostic standards and is inconsistent with other substantial evidence in the record. In order for an AP’s opinion to be rejected, the claim file must include specific reasons why the opinion is not well supported by medically acceptable clinical or diagnostic standards and is inconsistent with other substantial evidence in the record. (Effective October 3, 2005)”

In reality, it is also a well-known fact that in 2008 UnumProvident celebrated company wide the end of the reassessment with cake, lunches, cookies and parties, changed it name to Unum Group, and began its unfair, egregious claims practices all over again.

In my opinion, I don’t think there is anyone who can say that Unum Group is in compliance with the multi-state settlement agreement and there is no reason why the additional penalty of $145 million should not be imposed.

Unum Group’s excessive reliance of internal medical staff (and only its internal staff) to produce documentation opposing opinions rendered by insureds’ own qualified physicians is as well-known and recognizable today as it was in 2004 – perhaps even more so.

Misrepresentation of medical records and patient notes, “snatching” of key phrases favorable to it at the expense of all else in the record, ignorance of co-morbid impairment, processing the elimination of separate diagnoses one-by-one, and failure to overturn denials on appeal even when a preponderance of medical evidence is submitted continues to identify Unum Group as an “unlawful organization” and in violation of the multi-state settlement agreement.

Unum’s response of, “We don’t do that anymore” is not truthful in the face of hundreds of denials letters and claim files I’ve read in the last 12 years that document the company’s persistence to continue to target and deny legitimate, payable claims at the expense of our most vulnerable group in society – the disabled.

It wasn’t comforting when a very prominent attorney told me in 2015, “Unum is no better or worse than any other insurer these days.” As a consultant who views files and denial letters from all major US insurers, the only conclusion I could come to was that other insurers lowered their standards to Unum’s, not the other way around. That isn’t good news at all!

Any reasonable person or Unum insured might ask the question “Where are the state regulators and why aren’t they watching? Shouldn’t they be exercising considerable oversight to determine if the additional $145 million penalty should be imposed?”

In my opinion and belief, Unum’s “Conduct Market Consultants” (fixers) are exerting influence at the state level to keep audits, fines and penalties off the table. Any state department of insurance who conducts Unum random audits would NOT conclude the company is in compliance with any reasonable standard of claim review, not to mention the multi-state settlement.

In  2016, NCDI and its membership will be asking the all important questions – Is Unum in compliance with the multi-state settlement agreements ( including the California agreement), and what are state regulators doing to ensure compliance?

As a non-profit organization, NCDI and its membership will seek to obtain responses from the lead regulators as to Unum Group’s compliance.

The public expects no more, and no less.

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