Unum Updates – What Next?

The “hungry vulture’ strikes again with continous requests for more and more SSDI information to re-calculate SSDI awards looking for every nickel and dime it can find. Some claimants are asked to submit SSA paperwork over and over again allowing Unum to recalculate imaginary overpayments it swiftly removes from the next benefit checks.

SSDI overpayments have been an ongoing focus of Unum’s since late 2018 when it hired Lucens as its third-party SSDI award chaser. Despite the harassment of claimants who refuse to sign SSDI Authorizations, Unum continues to  request SSDI verifications of current and past benefits. One claimant remarked, “Is Unum so inaccurate with its accounting?” In my opinion, Unum needs cash flow and is hunkering down to seek out every last nickel and dime it can find.

March is corporate bonus month for Unum’s employees who receive salary percentage bonuses for supporting Unum’s agenda to deny claims. Unum’s claims handlers know exactly what they’re doing when legitimately payable claims are denied, and are paid handsomely to collude with management.

In addition, the best among highly skilled deniers will be chosen to go to Disneyland as part of the ASPIRE program, which is yet another of Unum’s indoctrination programs. Disneyland doesn’t seem to be much of a worthy reward for colluding with management to deny claims for profit. Still….many employees “aspire” to see Disney World. Go figure.

Bonuses are generally paid to all employees employed by October of the year previous and can range anywhere from 2-5%. Medical and management staff can receive higher or lower percentages depending on how well they contributed to “shareholder value”, a Unum buzzword for profit.

In my opinion, anytime incentive monetary gain is offered, the door is opened to claim review abuse.

At least one Unum claims handler communicated to a claimant that the company WOULD NOT give credit for SSDI attorney fees when calculating overpayments because he/she didn’t use Genex. Hello?

Welcome to Unum’s world of Unfair Trade Practices. Unum tried to do this several years ago but was challenged by attorneys with claims of unfair trade practices and the company stopped. Apparently, Unum reinstated the practice, according to one of Unum’s claims handlers.

From what I understand from the attorneys I spoke to, forcing claimants to use Unum’s (incompetent) third-party SSDI advocates is an Unfair Trade Practice. Not only is the claimant deprived of the opportunity of attorney/client privilege, more competent advocates, but Unum is forcing claimants to use advocates who provide all information directly to Unum creating a conflict of interest. Genex works for Unum, not for claimants.

This is not something that claimants should dismiss, or feel strong armed into doing. Genex, Advocator Group, Allsup etc. are not always the best choices to advocate for you. Claimants should have a choice whether or not to use Genex without penalty. What Unum is doing is an Unfair Trade Practice.

Signs Of Bad Faith Investigation – A Reminder

1. An insurer may be acting in bad faith if the insurer delays or denies investigation or payment without a reasonable basis for its delay or denial. ERISA claimants must be notified in writing at 45-day intervals (tolling letters) as to why the liability decision has not been made within the original 45 day time period. DI insureds cannot be “strung out there” without a decision for any reason.
2. Failure of insurer to acknowledge and reply promptly upon notification of a covered claim.
3. Failure of insurer to pay a covered claim as a result of failing to do a proper, prompt, and thorough investigation as to reasonable liability and damages based upon all available information. Insurers can engage in bad faith by “omission” by not undertaking investigations that would “shoot themselves in the foot.”
4. Failure of insurer to affirm or deny coverage of claims within a reasonable time upon receipt of claim and/or proofs of loss.
5. Failure to offer or attempt to effectuate a prompt, fair and reasonable evaluation of damages and equitable settlements of claims to insured within reasonable time where liability is reasonably clear.
6. Insurer attempts to settle a claim for less than the amount to which a reasonable person would have believed was entitled or attempts to substantially diminish a claim requiring an insured to initiate litigation.
7. Attempting to settle claims on the basis of an application and/or policy which was altered without notice, knowledge or consent of the insured.
8. Making payment(s) for claims without accompanying statement indicating the coverage for which payment(s) are being made.
9. Insurer failure to make known an arbitration award appeals policy in an attempt to settle a claim for less than the arbitration awarded.
10. Insurer requiring claimant or physician to submit both a preliminary claim report and formal proof of loss forms which contain substantially the same information. Requesting the same medical information over and over again or claiming to have not received it can be construed as bad faith.
11. Failure of insurer to promptly settle claims, where liability and coverage is reasonably clear under one portion of the insurance policy in order to influence settlements of coverage for another portion(s) of the policy.
12. Failure of insurer to promptly provide reasonable explanation and basis when denying or making a compromise offer of claim settlement.
13. Failure of insurer, when making a cash payout to settle a first party auto insured claim, to pay the same amount which the insurer would pay if repairs were made.
14. Requesting over burdensome documentation demands not required by the policy.
15. Reference or focusing on recovering on the uninsured portion of the loss.
16. Using illegal and fraudulent investigative methods and procedures. (Field reps showing up on the insured’s property without PI licenses?)
17. Using harassing, intrusive, or demeaning investigative methods and procedures which victimize the insured.
18. Failure of an insurer to settle a claim directly, when and where settlement is required, and instead requiring the insured to pursue a claim against another party first before offering settlement.
19. Failure of insurer to make full and satisfactory payment of a first party claim prior to requiring settlement or exhausting the limits of a third-party insurer (i.e. in uninsured motorist cases).
20. Failure of insurer to unreasonably refuse to waive subrogation thus hindering or preventing a claimant from reaching settlement with the party at fault (i.e. in uninsured motorist cases).
21. Unjustified contention and/or “lowballing” regarding the value of a loss. Offering unreasonably low settlements.
22. Intentionally withhold, misinterpret or misconstrue claims information and/or failure to not inform insured of provisions and covered benefits under the policy pertinent to a claim.
23. Attempts to use indiscriminate measures, reference and/or procedures that diminish or reduce the top line amount or value representing full payment of the claim.
24. Intentional or irresponsible non-disclosure and withholding of information, misinterpretation of file documents and/or policy provisions that would be in favor of the claimant. (Snatching from medical documents in its own favor at the expense of all else favorable to the insured.)
25. Unsubstantiated and unwarranted accusations of arson.
26. Wrongful threats not to pay claims.
27. Utilization and/or development of deceptive insurer schemes or use of outside company services set up or conducted to carry out the same false pretense schemes (i.e. “Independent Medical Examiner Paper Reviews”) for the purpose to be able to wrongfully deny or reduce payment of claims. (Consider the outsourced resources and “peer reviews” as an insurer scheme.)
28. Insurer advice to claimant not to hire a lawyer.
29. Treatment of insured’s represented by attorneys as insurer adversaries. (And/or consultants and advocates.)
30. Treatment of insured’s and claimants as adversaries.
31. Significant increase in amount of premium as a result of making a claim where insured was not at fault and in conflict with industry standards.
32. Cancellation of a policy as a result of making a claim or result of an accident where insured was not at fault and in conflict with industry standards.
33. Failure to live up to, conform, or comply to industry standards.
34. Using inaccurate or wrongful information of a factual or legal nature to diminish, deny, or delay payment of a claim.
35. Not being forthcoming with facts regarding coverage to deny, delay, or reduce the amount of the claim.
36. Using extreme undue persecution, wrongful and victimizing tactics and actions, meant to crush, threaten, thwart, intimidate, oppress, in order to scare away and get the claimant not to make or pursue a claim.
37. Failure to convey to insured’s settlement offers and demands of adversaries in accident and liability cases.
38. Changing or altering policy coverage without informing or receiving the consent of insured.
39. Representation by an insurer that an investigation “of fact” is taking place, knowing that no investigation is being done, in order to intentionally stop and dismiss an inquiry by a plaintiff, plaintiff’s attorney, or DOI examiner.
40. Biased investigation of that which is supposed to be neutral and unbiased.
41. Utilization of internal one-sided or outside companies biased schemes, such as in so-called “IME” bias (independent medical examiner bias), which are supposed to be objective and neutral, in order to wrongfully enable, facilitate, and support insurer’s position to fraudulently deny, reduce, or discontinue payments of claims.
42. Repeated and constant reference and intentional miscommunication and misrepresentation by insurer downplaying the size of a claim to insured’s attorney.
43. The same claims person of an insurer handling conflicting and both sides of the same or related claims.
44. Deviating from standard procedures called for in an insurer’s claims manuals.
45. Attempting to prevent the court or an insured’s attorney with due exception from securing a copy of an insurer’s claims manual. (Berkshire/Guardian does this.)
46. Abusing and/or misusing the judicial court system in order to delay or settle in good faith payment of a claim where liability to the claim is clear and the amount of the claim is reasonable in order to delay insurer’s having to make payment of a claim.
47. Fraudulently misrepresenting and revealing various conflicting financial information that mischaracterizes the true financial information and status of an insurer.
48. Attempting to shift blame and responsibility of investigation to insured and away from the insurer.
49. Threatening to harm insured and/or take legal action against an insured to recover amounts paid by insurer as in a short-term workmen’s compensation or short-term disability claim in order for insurer to discontinue having to make payment on a longer or long-term basis.
50. Insurer refusal to settle a third party claim against an insured within the limits of the insured’s policy thereby exposing the insured to additional liability.
51. Intentionally misinterpreting or misconstruing the law to the disadvantage of the insured and benefit of the insurer.
52. Deny treatment for a covered health benefit because of its expensive cost and instead misrepresenting and suggesting a less costly procedure in its place to be just as effective when it is not.
53. Unreasonable denial of a covered health benefit because of its high cost.
54. Unreasonable misinterpretation of policy language.
55. Taking undue excessive advantage of unlimited time when knowing there may be no time limitations established on alleged investigations of such matters or matters of fact.
56. Making health insured patients pay their standard co-pay when the cost of both the drug and the pharmacy’s fee for dispensing the managed care prescription is lower than the co-pay amount.
57. Causing health insured’s to pay a co pay that is higher than what the cost of the prescription is to the insurer because of common secretive rebate deals between insurers and drug manufacturers which subsequently are not disclosed and therefore do not accurately represent the true cost of the drug.
58. Health insurers not acting in the best interested of the patient and/or acting for their own self-enrichment at the health expense and disadvantage of the patient.
59. Some health insurer secretive deals are alleged to result in the health insurer selection of a more expensive drug to be on their list of acceptable drugs (“Formulary List”), services or procedures deceptively generating greater insurer profits, excessive higher costs to patients and illegally billing federal Medicare or state Medicaid programs.
60. Good faith insurers look for and find ways to accept and pay claims properly and promptly…bad faith insurers unlawfully look for and find ways to not pay, delay, diminish, disapprove, and deny payment of claims.

Daily Buzz – Monday, February 17, 2020

Just say, “No”.

Recent information has it that Unum may be asking insureds to allow the company to speak with spouses and children. While I would think such a request is an obvious “stick it in your ear” kind of question, callers to DCS are flipping out about it wondering what will happen if they don’t allow it.

Spouses and children are not parties to any disability contract and are NOT required to be brought in as witnesses against their family members. It seems obvious that the reason for the request is to find “inconsistent” stories about activities by asking minors what the disabled parent is doing. Insurance companies do not have the right to involve, or bring in any persons who are not parties to a disability contract. This is true of peers, neighbors, and co-workers. This is one time Unum needs to be told “stuff it” and sent on its way.

Contestability

This issue only involves IDI insureds and can be a major stone in one’s shoe due to misunderstandings at the time of application and underwriting. “Contestability” as you know, is a provision included in IDI policies that provides both insurers and insureds with a buffer for information that is found to be inaccurate or misrepresented within 2 years of the Effective Date of Coverage. If any misrepresentations are found after two years, there is no penalty and claims cannot be denied or policies rescinded.

However, questions asked are often deceiving and not well understood. For example, Standard’s “Application for Disability Insurance” asks questions in two different ways:

1. “Have you had, been told you had, been treated or diagnosed by a medical practitioner as having…..” There are 13 specific questions ranging from disorders of the eye, ear, nose, throat to cysts, back or neck pain, FMS and CFS, asthma, high blood pressure etc. In fact, Standard’s questionnaire makes one wonder if any disability would be covered.
2. A second set of questions,  namely, “Other than as stated in other answers, have you within the last 5 years…?” This is an entirely different way of asking a question. Number (1) implies “have you EVER had”, and number (2) asks specifically within the last 5 years.

Some of these questions Standard asks are outlandish. “In the last 3 years have you had any physical or mental condition or symptom that has not been treated or diagnosed?” What does this question even mean? How is the insured supposed to answer this question? Did you have a headache…cut on finger…what? I remember Unum tried to get away with rescinding a policy because the insured never revealed she took Advil for a headache.

Again, contestability issues can be easily resolved by NOT filing claims for the first two years after the Effective Date of Coverage. Insurance companies go way beyond what’s reasonable with investigations regarding “misrepresentation.”

For those who may not know, insurers can rescind the policy, deny benefits, or engage in new underwriting recalculating what premium should have been had the misrepresentation not been made. In order to continue the policy, the insured would need to “pay up” all outstanding premium. However, it’s also likely the insurance company will exclude your current claimed disability from coverage in the future.

 

 

Friday Q & A On Thursday

Does Prudential try to deny claims?

Prudential is at least in the top five ERISA group employers who actively seek to deny claims. In fact, Prudential is well-known in the industry for its unfair and discriminative denials of mental health claims. Patient notes are always requested, misrepresented, and cited in forthcoming denials.

In the past, even though mental health providers are not required to release patient notes, Prudential refused to pay claims unless actual mental health therapy notes were released.

Prudential also allows RNs to review claims when they are not qualified to do so in the area of claimed disability. Considering the amount of financial reserve involved with some claims, the lack of MD medical review is a very arbitrary and capricious error. Since many execs now working for Prudential were fired by Unum, the company uses the old hat Unum “claim killer” physicians as claim reviewers. It’s the same story over and over again…..Disability insurer targeting and denying payable claims! Prudential ranks in the top 5 most unfair disability claims reviewers.

How does HIPAA apply to auto liability insurance?

Auto liability insurance could involve accidental or personal injury in which medical records are requested and reviewed. HIPAA Authorizations to release medical records may still apply here depending on the circumstances. HIPAA applies to all medical records transmitted by electronic means. Amendments have been passed that include other types of transfers of medical information, but the new regs are allowing more and more information to be released with less mandated regulation.

What is the definition of the word “prolonged” when written in medical records?

This is actually a very good question and one which I doubt claims handlers would be able to answer. Looking at the disability definition of both “prolonged and repetitive”, it seems reasonable to say that since a “material” duty is defined as a “work activity that is required for more than 20% of an 8-hour workday” the work task would have to at least meet that criteria.

In addition,  “prolonged” also suggests that the work activity required is performed for longer periods of time. “Periods of time” is relative (differs) depending on the claimed disability and the task itself. For example, an administrative assistant with carpal tunnel would have difficulty typing greater than 10-15 minutes, while a claimant with FMS may have difficulty only after 1 hour due to fatigue.

This is why it is extremely important for treating physicians to determine specific restrictions that actually define what “prolonged and repetitive” is for each patient in accordance with objective MRI/CAT scan results and clinical observation.

Can Unum be charged for disability medical records?

Of course. But, claimants who are required to submit paperwork for updates must cover any costs themselves. If, however, Unum requests information directly from physicians then the doctors should bill and demand payment before records are actually sent. A beginning cost should be at least $100 since Unum always offers much less.

I have always recommended to physicians that they bill for their time,  use of resources such as copy machines, the costs of administrative office staff, and any other fixed costs related to taking harassing phone calls and generating paperwork. I find that charging Unum with the real costs of providing patient records is a dis-incentive for continually asking for the same information over and over again. Although most physicians “feel funny” about invoicing Unum, they should always send a bill when requests are received directly from the company. Perhaps my readers should remind their physicians to bill as appropriate.

What is an AP & C?

Another great question. Actually, I’ve written several detailed articles on this blog about Unum’s Advance Pay and Close. An AP & C is when Unum decides you are able to return to work and then “pays you out” up to 6 months on your claim anticipating you will be able to go back to work.

For example, claimant B’s medical doctor documented she probably could go back to work in 6 months, or worse yet, Unum’s claims handler used MD Advisor’s recovery period software recommendation to state when B can go back to work. Right away, Lucens or the claims handler will send B a letter saying they are going to give her six months of benefits in anticipation of a return to work based on the evidence they have. The letter says that if B is unable to return to work within the 6 months, she can come back of claim.

Unum used to have very specific rules regarding offering AP & Cs.

• The claimant must agree to accept the offer of AP & C.
• The lump sum can only be up 6 months of benefits.
• There must be specific documentation from an employer stating that a return to work is approved and expected.
• No ERISA disclosure in the letters is permitted since an AP & C is regarded more as a settlement, rather than a denial.

Anyone can easily see how this is abused by Unum. Usually, AP & Cs are offered prior to holidays because it is presumed by Unum that certain groups of people will need money. Let’s not sell Unum short either. Tempted by the offer of getting up to 6 months benefits in a lump-sum encourages people to think, “I’ll take the money now and worry about the return to work six months down the road.”

The problem is, what if you are unable to return to work and you want to take Unum at it’s word that you can come back on claim? Forget it. The ensuing investigation will be more intense than when you initially applied and will likely be denied. AND, you don’t have any appeal rights! Please be careful with this. When Unum dangles lump-sums of money in front of claimants they may accept the offer without realizing the consequences.

 

Surveillance Video – “Seeing Is Believing”

Most of my readers know that I often write about the necessity of abiding by medical restrictions and limitations so as not to provide insurers with “inconsistency of report” that  often leads to denied claims.

A case was brought to my attention: Farron Russell Creed v. Hartford Life and Accident Insurance Company, Case No. 2:19-cv-1072 in the U.S. District Court Southern Eastern Division.

Mr. Creed worked for Kenworth Truck Company as an assembly specialist, but in May 2014 was involved in a motorcycle accident in which he sustained substantial injuries. After undergoing several surgeries, he was unable to return to work and filed an LTD claim with The Hartford.

Hartford subsequently approved his LTD claim but on February 19, 2018 Hartford terminated his claim alleging he was no longer disabled under the Plan. Hartford relied on updated medical records, video surveillance, an interview with Mr. Creed, new medical opinions and an employability study.

Mr. Creed’s medical providers provided various documenation that literally did not help Mr. Creed at all. Dr. Taylor remarked, “…Mr. Creed drove to his appointment on his motorcycle“, and notes from his pain management physician, Dr. Patel stated, “…stays active and enjoys his hobbies, especially motorcycle riding.”

Surveillance was conducted. The resultant video from September and October 2019 showed Mr. Creed driving his motorcycle and doing things that he later claimed he could not do – kneeling, bending, stoopiing, reaching and pulling. The video also showed Mr. Creed using his left arm in an unlimited fashion and moving his neck, arms and hand freely.

After the surveillance, Hartford requested a field interview in person and interviewed Mr. Creed without telling him about the surveillance. During the interview, Mr. Creed indicated he could not return to work due to leg and neck pain sustained as a result of the accident. He also said he needed knee surgery to repair a torn meniscus. This information was in complete conflict with the surveillance video obtained before the interview.

Subsequently, as the result of an Independent Medical report, it was determined that Mr. Creed was capable of working 40 hours a week with temporal restrictions regarding standing and walking as well as weight restrictiions and lifting.

The video surveillance was persuasive since it showed Mr. Creed having more functiionality than he claimed possible, and moving in ways that he claimed he could not.

Based on the surveillance and additional medical reports the Judge in this case sided with The Hartford in deciding The Hartford did not act in an arbitrary and capricious manner.

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This case is a very good example of the fact that you cannot undo surveillance, or “inconsistency of report”. I want to point out that it is a tactic, or strategy for any insurance company to either do a phone interview, or field visit after conducting surveillance specifically for the purpose of catching inconsistencies.

This is why I have always recommended communications “in writing only”. Unfortunately, some claimants push the envelope too far and do not prevail in court. Those who may think I go a bit overboard with my articles may want to consider this case very carefully. Insureds should never exceed their medical restrictions and limitations. In this day and age it is also important to censor out what you say to doctors about your activities.

Living With A Disability Claim – Kindness Counts!

Today, it almost seems as though we live in a convoluted world where everything said and done seems to be offensive to someone. This is especially true for those who live in a world made up of fear, pain, and depression resulting from disability.

What I’ve noticed though is that people in general no longer go out of their way to be kind to one another.  Very few passer-bys smile anymore when approached. Remember when “random acts of kindness” became the big headline of the day? Or, “Pay it Forward?” Perhaps those concepts quickly passed us by, replaced only with recriminations and distain for others.

“Kindness” is a major necessity for all of us. I came across the following on someone’s website the other day I thought was well-written and well-said.

Today you could be standing next to someoone who is trying their best not to fall apart. So whatever you do today, do it with kindess in your heart.

To me, “kindness” can be defined as the “outward reactions of human beings to one another that evidence compassion, sympathy and love for the humanity and failings in all of us.” (Yes, this is my definition!) In the end, kindness is an opportunity of offering visual acceptance and solidarity to those who need just “one nice word” to  make their day.

Finally, “kindness” is a free offering of support to those you may not even know. Sometimes, those who are disabled live alone, and rarely come in contact with uplifting energies to keep them going.

Because our world is overwhelmed with bitterness, it is even more important for all of us to keep “kindness” alive. So, I’m asking all of my readers and clients to remember that a smile might be the only good thing that happens to someone today.

In fact another good saying  I like is: “Never look down on someone unless you’re reaching to help them up.”

Therefore, I’m sending everyone a smile today letting you know I support and care about you. Have a great day and pay the kindness forward when you can.

 

 

 

 

 

 

 

 

Under The Magnifying Glass – Editorial By Linda Nee

It has never occurred to me that insureds, especially those who are considering retaining my services, conduct investigations of me, suspiciously trying to challenge my credibility.

Not once in the last 20 years have I ever pulled a credit rating or checked out any insured’s social media prior to bringing them on a client. I don’t know why I never considered the possibility of “internet stalking” of me, but surprisingly it’s not the insurance industry who’s stalking me, it’s insureds!

First, let me say that I get it – I’m just a voice on the phone, or someone who writes a blog. Still, if you search my name on the Internet, there are listings every where. It’s hard to imagine that a 20+ year career in disability claims management has done nothing but make me invisible to those who are looking for new information. A certain amount of “due diligence” is normal and expected, but I found out a few things recently that seem a little odd.

First, I found out that because I have an answering service, people find “that’s suspicious.”  Because of the blog and the numbers of calls I get every day, in my mind at least, I wanted to make sure I didn’t miss any calls and had an opportunity to speak with persons who take their time to contact me. Still, at least one person told me that because I have an answering service, “I was suspicious.” The person who said this then kept calling the answering service demanding information about DCS, Inc. including my tax information. Boy, do I know how many of you feel when the insurance companies investigate you!

Another person asked me to provide the names and numbers of several neighbors, my town hall, and a local attorney, who could verify I’ve lived in my town and house for the last 20 years. They weren’t comfortable not knowing this. Someone also wanted me to call an attorney I’ve worked for before and have him call to verify I am who I say I am. A Consultant needs to draw the line somewhere and I refused the last two requests. The next comment was “You’re a scammer!” Really?

Then, there’s the issue of my Facebook page which is not used for business purposes, and in fact, I shut down any claim discussion that begins there. My Facebook page contains several of my art projects that probably rate somewhere between, “Not so bad” but “not good either.” Still, in my spare time I like to paint with Acrylics and sometimes post my pictures on my Facebook – the only credible use of social media in my opinion. In the future, I may post a few of my short stories and poetry there, but someone may think I’m a writer and not a Consultant……well, can I be both?

Finally, I found out that people access satellite views of my house, property and cars parked out front. Gee, I think the current satellite view isn’t up to date because the lilac bushes are still there when I had them removed several years ago. Is this getting a bit silly or what?

Somehow I thought that my knowledge and experience in claims management made me immune to this kind of thing. I am always willing to provide references to insureds. I guess I never expected this kind of investigation from the very people I’m trying to help. Does it seem reasonable that the insurance industry finds me more credible than the people I’m helping?

Anyone who wants to ask me questions can call me, and if they are reasonable I’ll answer them. References are always available. It’s not necessary to find my house on the satellite is it? Just call and ask.

I can really relate to how my clients feel when they call me to say they noticed surveillance in their back yard. It doesn’t feel right to me, although I’m sure insured’s will continue to investigate the Consultant to make sure I’m who I say I am.

If I were asked right now I’d have to say this sounds a bit more like stalking than investigating. What do you think? Where do you think the line is between investigating my experience and credentials as a Consultant versus looking up the color of my house, and demanding my neighbor’s phone numbers?

In my opinion this type of investigation by insureds is way over the top.