Before Filing A Disability Claim – Are You Medically Ready?

When you begin to experience medical symptoms you can identify as causing poor performance at work on a consistent basis, it’s a good idea before leaving the job to seek consultation from a qualified physician with appropriate credentials to evaluate what’s wrong.

Although you may have already sought medical treatment resulting in one or more diagnoses, discussions about disability with treating physicians are essential prior to actually leaving work. One of the worst things employees can do is “not show up” for work without having a treating physician document the inability to work.

A “best practice” for patients is to provide physicians with a copy of their job description and discuss item-by-item difficulties with specific job tasks referred to as “material and substantial duties.” Claimants may be unable to perform some, but not all of their duties, while others may find it impossible to perform any duties expected of them by their employers.

Unfortunately, today’s reality is that patients are expected to be “in and out of medical consultation in fifteen minutes” leaving very little time for disability conversations with their doctors. However, patients can arrange for “extended office visits”, alerting physicians of a patient’s need for a longer consultation.

Physicians are not “mind readers” and appreciate patients who share their physical and mental limitations while working. A job description and an honest conversation allows your physician to objectively gauge the severity of a diagnosis in combination with what you are realistically able to do on the job such as:

• Are you having problems sustaining a full 8-hour a day or 40-hour workweek?
• Do you have severe levels of pain while at work requiring frequent breaks?
• Do you find yourself frequently confused, unable to remember, or unable to think clearly enough to make important decisions?
• Are you receiving poor performance reviews because you can’t do your job, or is your employer complaining about attendance?
• Are you having difficulties getting along with your co-workers or problems interacting on a social level?
• Do you experience high levels of pain during the work day?
• Are you harsh or abrasive when dealing with customers?
• Are you frequently absent from work and quickly use up sick leave?
• Have you requested FMLA leave more than once in a given year?
• Have you had to ask your employer for work-at-home accommodations or special workstation equipment?
• Are you so fatigued at work that you fall asleep or find it hard to stay awake?
• Are you placing yourself or others at risk because you drive yourself to and from work?

Using your job description as a guide, discuss with your doctors all of the difficulties you’ve had at work and why you find it harder and harder to continue performing the “material and substantial “duties of your job or occupation. Explain to your physicians how many sick days you’ve had in the last month and how often you’ve had to leave work early for medical reasons and why.

For the most part, physicians are supportive when patients take the time to fully explain why they are unable to sustain or perform consistent work. At the same time, physicians have little regard for patients who show up in the office insisting he/she support their disability and basically “do what the patient says.”

            “I can’t take it anymore, doc, my boss is really giving me a hard time, and I need to go out on disability. Please sign my paperwork.”

Approaching a treating physician in this way probably won’t get you his/her support for a disability claim. Physicians much prefer to make medical diagnoses and disability decisions independently. Walking into a physician’s office with a list of self-diagnosed impairments is not the way to speak to physicians about disability leave.

            “Dr. Brown, I’ve tried very hard to remain at work, but I’m finding it more and more difficult to lift those legal boxes and files without having pain for several hours. My job description requires me to lift up to 50 pounds frequently and my back just won’t let me do that anymore. I’m in pain all the time.”

Dr. Brown most likely will order a set of MRIs or x-rays and pinpoint the herniated or bulging disc causing you to have so much pain. Afterward, he may recommend a period of disability because it is supported by objective evidence or because there is a longstanding history to support the impairment. Disability determination is always related to the patient’s inability to perform his/her job and is supported by a series of objective tests, medical history, and/or clinical observation. To ignore the occupational side of disability could be disastrous to anu claim.

Although there are many impairments that are NOT diagnosed as a result of objective evidence, physicians are permitted to base their opinions from “clinical analysis and consultations” in the past. This is why it is extremely important for employees to seek medical treatment early rather than later when it becomes evident a work leave is necessary.

 For some, the decision to apply for disability is the result of a long history of managing impairments for the sole purpose of remaining at work and keeping their jobs. However, insurers, looking for “triggers” to challenge disability claims ask, “What changed? You’ve been working with your symptoms for many years. Why are you submitting a claim now?”

The “what changed defense” is easy enough to explain since nearly all disabled persons do all they can to remain at work until, due to medical necessity, it is no longer possible to work. Sometimes there is no specific “trigger” to filing a disability claim except a long history working with medical impairments that are no longer manageable.

Mental health and self-reported disabilities are much more difficult to diagnose and support for disability since there is no objective evidence such as lab or MRI results to back-up any diagnoses made. Mental health treatment providers, for example, rely on histories of consultation, observation, and reported behavior to make their diagnoses. This is referred to as “clinical proof of claim” and is just as credible as “objective evidence” in supporting disability claims.

Psychologists and other therapists generally do not sign disability paperwork for new patients. Therefore, when it becomes obvious depression and anxiety, or other mental health issues are disrupting and preventing work, or regular attendance at work, treatment should begin right away to establish a history in case it becomes necessary to leave work in the future.

        “Dr. Brown, I’ve been working for nearly 10 years now with my back pain and I’m finally ready to retire. I just can’t do it anymore. I want to retire. Will you support my disability claim?”

            “I can’t work any longer with my migraines, doc, besides my employer is laying me off and I have too much stress. I want to go out on disability. Can you help me?”

Unfortunately, the above statements are very common mistakes made by employees with medical impairments who have struggled to remain on the job for many years. It is important to realize disability insurance is NOT retirement or unemployment income, but replacement income for medical disability only. As a result, a typical notation in the patient notes such as, “John is having difficulty at work, and he wants to retire. I agree” is a sure guarantee of a dead-in-the-water disability claim.

Insureds and claimants should never associate or use the word “retirement” when discussing disability with a physician since once written in the patient notes, insurers may allege he/she went out of work, not because they were medically impaired, but because retirement seemed a better option. Such patient notes aren’t going to be helpful to support medical disability when read by disability insurers looking to deny claims.

Another common error made by claimants is the presumption that a diagnosis is equal to a disability. For example, Marjorie was recently diagnosed with Type II Diabetes Mellitus with an A1C of 11%. Alarmed and scared by the initial lab reports, Marjorie started crying and requested her physician sign paperwork supporting short-term disability. While her physician gave in and took her out of work for a month, it is unlikely (barring any serious complications) her disability insurer will approve an STD claim for Type II Diabetes without more serious complications involving uncontrolled glucose levels, neuropathy or some degree of blindness.

Physicians actually have more authority than they think they do when certifying medical disability – it’s the paperwork they are opposed to. Most physician caseloads include up to thirty percent “disabled” individuals whether it’s for worker’s compensation, social security, or private disability.

Filling out paperwork is not cost-effective, and utilizes the physician’s office administrative staff, office machines and phones, as well as his/her own time in attempting to determine how to “fill in the boxes” on various forms from different agencies and insurers.

Although physicians generally have more experience in filling out paperwork for workman’s compensation and social security, private disability insurance forms are somewhat unique and require very specific documented “restrictions and limitations.” All good intentions aside, most physicians are unskilled in writing disability restrictions and limitations and wish the “problem” of disability paperwork would just go away.

Early discussions with your physician are essential prior to leaving work since it is extremely important to develop written histories of medical consultation and treatment prior to walking off the job. Disability insurers will request copies of patient notes to ensure claimants have sought appropriate medical treatment prior to approving the payment of any disability claim.

 Remember, only physicians can determine disability status, therefore, key information to filing initial applications is included in the patient notes, i.e. the date of disability, diagnosis and treatment plan. The “date of disability” (DOD) is extremely important since it is the date which begins the Elimination Period, and determines the first benefit payment date.

The date of disability, or more specifically, the date your physician restricts you from working is extremely important to any disability claim and should be clearly documented in the patient notes. It makes perfect sense that since your physician is the only person who can “take you out of work” he/she should also be the person who determines when disability begins.

Most insurance companies will use either the day after your last day worked, or your first date of treatment as the date of disability. However, “dates of disability” (DOD) should be established and documented in patient notes by treating physicians before submitting any claim to the insurance company.  If not, the insurance company will determine dates of disability claimants may not agree with.

The lessons here in this post are to realize that private disability claims are not “entitlements” to automatic benefits, but require claimants to meet certain conditions of impairment that prevent work certified by one or more physicians.

Only qualified physicians can take claimants out of work and only physicians can release patients to return to the workplace. Leaving work on disability the proper way, supported by qualified physicians is the first primary action claimants make to support claims in a credible way.

All of the above also applies to Individual Income Replacement policies since consultations with physicians remain the same.

Medically preparing for a disability claim is just as important as the impairment itself. Excluding a catastrophic event, such as a heart attack, a disability claim should be prepared and well thought out before making application.

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If you are having difficulty in making application for disability benefits and need to speak with an expert please feel free to give me a call.

DCS is a national consulting organization that provides expert claims management services to those with private insurance. I offer free initial consultation and I’m happy to discuss how you can become a DCS client.

If you need assistance with filling out your update forms or questionnaires, please feel free to give me a call. I offer reasonable per hour fees in addition to full management assistance.

If you are interested in becoming a DCS client, please feel free to visit my website at: http://www.disabilityclaimssolutions.com

• Telephone: (207) 793-4593
• Fax: (207) 274-2331

Detailed information about DCS, Inc. can also be viewed on this blog by clicking the “Consulting Services” Tab from the Lindanee’s BlogHome Page.

Friday Q & A

What are Unum’s Core Values?

Gee, I haven’t been asked this question in a while. Yes, at least publicly, Unum does have a Mission Statement and Core Values. See below from Unum’s Internet marketing pages:

Mission Statement

Our mission is to help protect people financially when they’re injured or ill and need it most. In today’s environment of economically fragile families, financial protection benefits are more important than ever.

Vision Statement

We will be the leading provider of employee benefits products and services that help employers manage their businesses and employees protect their families and livelihoods.

Values

• Integrity
• Commitment
• Accountability

Oops. In reality, Unum doesn’t “help protect people financially when they’re injured or ill and need it most”, and I’m pretty sure no one would associate the word “integrity” to a company with such a terrible reputation for making unfair claims decisions. Unum very well may be the leading provider of Group STD/LTD, but the company does it’s job badly.

Does Unum have rehabilitation programs?

Yes, in fact most policies contain rehabilitation provisions, but it’s risky to ask Unum for rehab assistance. One of the first things Unum will do is contact your physicians for work releases so that you can participate in work activities. Once they have the work releases claims are denied citing, “since your physician released you to return to work you no longer meet the definition of disability.”

Unsuspecting Unum insureds must realize that any rehab program assumes an eventual full-time return to work followed by a termination of benefits. Unum isn’t offering rehab to help you, it’s offering rehab to eventually deny your claim. Very few rehab programs are successful, but my suggestion is that if you really want to trust Unum to help you return to work, get everything is writing. Don’t trust that Unum will work to help you, because it’s only working to help itself.

Rick Josephs again…?

I keep getting questions about one of Unum’s complaint specialists, Rick Josephs, and I have at least two posts about him. Suffice it to say that I knew him as a peer claims handler and he wasn’t a very good one. Unum made him a Complaints Specialist – go figure!

Filing an internal complaint with Unum is a waste of anyone’s time. In response to complaints the so-called specialists reiterate the history of the claim and defend the company with a ridiculous “we did nothing wrong” 5 page letter. Unum’s internal complaint department doesn’t solve problems, it defends the company line all the way. I wouldn’t waste your time.

DMS is very unfriendly, or is it just me?

No, DMS is the rudest, most out-to-get-you insurance company I am aware of. As a reinsurer it marches to a different drummer with frequent doctor shopping requests for IMEs, low-ball settlement offers, and claims handlers from hell.

Technically, reinsurers aren’t insurance companies at all, but are more like holding companies or financial investment entities who buy up the risk of certain product lines such as MONY, for the intended purpose of getting rid of the claims at a profit. State Departments of Insurance will tell you DMS is not under their jurisdiction although some will write a letter to find out what’s going on.

There are only three directions DMS takes: 1) settle the claim, 2) deny the claim and 3) engage in repeated IMEs until eventually a doctor comes up with an opinion to support denial. Clearly, DMS “doctor shops” for supporting opinions and is very disrespectful to insureds.

Did You Know?

Lucens Gets Around

Lucens is apparently getting around since new information to DCS indicates Reliance Standard is using the company to offer settlements. This is in addition to Sun Life and Unum’s SSDI file-chasing. It’s likely Lucens is hooked-up with other insurers as third-party “somethings”.

As far as I can tell, lump-sum settlement offers coming from a third-party aren’t doing very well since insureds are skeptical to deal with them. Information I received is that the actual offers are considerably low. Insureds and claimants should be very careful in reviewing settlement offers from Lucens or insurers. Low settlement offers aren’t better than nothing.

Field Visits and Surveillance are Booming

Insureds are reporting to DCS, Inc. that they are being asked to submit to a field interview, or have spotted surveillance just outside their front doors. I’m not surprised that insurers are aggressively stepping up risk activities to prepare for 1st Qtr. profitability at the end of March.

Insured need to be prepared for field interviews and surveillance can be managed. The important thing to remember is that insurers are permitted field visits if it is written in the Plan or policy, and surveillance is a given. Such is the life of insureds receiving benefits from any insurance company and it should be anticipated and expected. I know these “risk management” activities feel like invasions of privacy, but in most instances insurers are permitted to do them.

Doctors Throwing Tantrums

Former treating physicians are more likely to throw patients under the denial bus than ever before. Orthopedic Surgeons top the list of specialty physicians who often refuse to continue to support disability followed by Physical Medicine and Rehabilitation (PM&R) docs thinking that everyone can be rehabilitated. (That’s where their money is!)

Doctors who are less likely to be supportive concoct statements such as, “Unum sent me the forms directly and I have to be the one to fax them back.” This is an untrue assessment since the patient has the right to see what is being faxed anywhere concerning their health.

Physicians who insist on faxing information back to any insurer without you seeing it are probably not being honest in reporting to you what the response was. Insureds should always ask for a copy of what was actually faxed to keep your doctor honest. Bottom line, any physician who balks at filling out forms, or insists on faxing back information from his office should be replaced.

Although I’m not one to suggest interrupting medical care, I do recommend that insureds seek out other physicians who are more honest in dealing with medical information and who they communicate it to. Doctors who refuse to allow the patient to have a say about their medical records should be terminated and insureds should move on.

IME Physicians Who Treat You During The Evaluation

The role of an IME physician is not to offer treatment advice to the insured. IME physicians as a rule do not have complete medical histories and only have the medical records insurers tend to give them. Any IME physician who criticizes your medical care or suggests what kind of care you should have is overstepping their authority.

The only role IME physicians have is to report the basis of their own visual evaluation and provide a peer paper review opinion as to whether the individual can work or not. Neuropsychological evaluations go a step further in rendering diagnoses based on the scoring of the raw data, but IME physicians should not render treatment advice to those they evaluate. If this happens to you, share the information with your treating physician as soon as possible.

Unum W-2s

Although DCS does not recommend using Unum’s website portal, I did give the go ahead to open it to obtain W-2s. Unum’s procedures for obtaining W-2s outside of the portal are miserable. Just delete all cookies and history after visiting the portal. I would imagine other insurers are doing the same things, so be very careful and make sure you delete the cookies and computer history afterward.

I don’t recommend these portals for security and tracking reasons.

Higher Benefits – Permanent Targeting

In general, monthly benefits over $3,000/month are permanent targets for claim denial. Although some insurers still deny low value claims, or claims approaching maximum duration, by far, the greatest group of targeted claims are those with possible $1M in financial reserve. This is why IDI claims often receive the lion’s share of risk management activity and bad faith.

Not to be left behind, ERISA claims are much easier to deny. Unum, for example, is targeting a $10,000/month ERISA LTD claim while the insured’s IDI policy with a much lower benefit is left alone. “Targeting” high value disability claims and going for the “biggest bang for the buck” represents the majority of “bad faith” and unfair claims practices by most insurers.

The probability of maintaining a high value claim to maximum duration is, based on my own experience, around 30%.

 

 

Use GENEX Or Else! An Unwelcome Threat by Unum

A letter came across my desk today from a Unum Offset Coordinator to a claimant threatening to remove an estimate from benefits for SSDI if he did not sign on with GENEX. The letter was quite accusatory because “GENEX has been trying to get in touch with you, but you didn’t respond.”

Unum has a long history with GENEX – on and off over the years, sometimes bad, sometimes not so bad, but always, in my opinion, incompetent.

GENEX is one of Unum’s third-party SSDI advocates. Unum’s deals with the company have changed considerably over the last two decades, and for quite some time attorneys and insurance regulators were following the money to find out just who was benefitting from services: Unum or GENEX.

In the past, GENEX was a wholly owned subsidiary of Unum’s, which regulators later decided was a conflict of interest. GENEX’ services to Unum at one time included claim triage, any occupation investigations, SSDI advocate, and medical reviewers. Nowadays, it appears GENEX is providing SSDI Advocacy but from where I’m sitting not to  many people want to sign on.

Coincidentally, I received the following email from a non-client today.

Hello Linda, I’m hoping that you can answer a question for me. If I’m not happy with the way Genex services has represented me in trying to get my SSDI; can I fire them? I’m no longer receiving LTD so must I stay with Genex? I was denied for the second time and they have put in to go before a judge, but when I got the letter from Social Security denying me I saw where Genex is trying to get it from breast cancer and neuropathy. I went through breast cancer from Feb. 2017 until my last treatment in August of 2018… 

So as you can see they have not represented me right. Plus I have not had the lawyer contact me not even once. The only person from Genex who contacted me was a lady named [name deleted]. I  am not happy with them at all. Since Unum is no longer paying me, Do I have to stay with Genex? The lady said it would be 12- 18 months before the hearing and I can’t do that. I was thinking I would get all the evidence myself, write to my congressman to try to hurry up the process, & maybe even find a local lawyer to whom I can communicate with. I have no income, no insurance now that cobra dropped me, and my 25 yr old daughter is having to support me. I have fallen into a deep depression and no matter how much I search I can’t find any answers. I lucked up on your blog so could you help me?

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Actually, no one has to use GENEX and clearly DCS, Inc. does not recommend any of the third-party SSDI advocates such as Advocator Group, Allsup, or GENEX. But, more to the point, the issue in today’s letter is Unum’s new “threat” that either you respond and use GENEX within a certain period of time or “we [Unum] will reduce your benefit with an offset for SSDI.”

What seems to be happening is that Unum’s reps contact GENEX who then contacts you, leaving you to believe you don’t have a choice in the matter.  Well, you do!

All insureds and claimants have the right to make application for SSDI online. The Social Security Administration provides the opportunity to file claims online and everyone has the right to file in that way. The actual Application is quite lengthy and picky to use, but if you want to file your own SSDI application online that is your right.

DCS, Inc. recommends that claimants retain a local SSDI attorney for assistance. Application information provided to the SSDI attorney is “privileged” and claimants need not worry about Unum (or any other insurance company) getting access to it.

In addition, your own attorney works for YOU, not UNUM and is an expert in SSDI since that’s all they do. There is no upfront cash outlay because attorneys fees are paid on a contingency basis directly from SSA.

Unum’s new way of “pushing” GENEX on claimants who naively think they have no choice has got to be some sort of Fair Trade Act violation I would think. It would be different if Unum wrote to claimants advising them they have an option of using GENEX, or getting their own attorneys, or filing online. But, it doesn’t.

GENEX is positioned in Unum’s letters in such a way to lead claimants to believe they must use GENEX. And, claimant information is automatically forwarded to GENEX without the claimant’s permission – again leading claimants to believe they have no choice.

I know there are attorneys who read this blog and I would strongly advise that they look into this matter. But, let’s be clear….claimants do not have to use GENEX as an advocate to file SSDI claims, and it is recommended that they not sign on with any third-party advocate recommended by insurers.

If you receive a letter from Unum threatening to offset your benefit unless you contact GENEX by a certain date, just send a fax letting your claims handler know you intend to retain your own attorney, or will be filling online. If you have filed online, then I recommend sending the confirmation of the application to Unum, or better yet, contacting SSA and asking for a more formal verification letter that you have applied.

If you’ve retained your own attorney, provide Unum with his/her contact information. Bottom line here, claimants have the right to file SSDI applications online, or retain their own attorneys as they see fit.

Unum is acting in a deceptive way to make sure you sign on with GENEX. Don’t fall for the scam. Your policy provisions tell you that as long as you make application for SSDI benefits and continue through all appeals, there will be no estimated offsets taken from your benefits. As long as you provide proof of application, you have met that Plan or policy duty.

Unum is entirely wrong for positioning GENEX as mandatory under threat of reducing benefits. These types of actions on the part of Unum are deceptive and misleading. It’s really too bad, but the company rarely tells claimants the truth about anything.

And yes, you can fire GENEX, Allsup, and Advocator Group if you feel your interests are best served with a skillful attorney. Notify the Unum claims handler that you no longer want GENEX to assist you and request that all GENEX Authorizations signed to date be null and void. Your new SSDI attorney will instruct you on what he needs to do in order to obtain your records and a release from GENEX.

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If you have any questions concerning your application rights for advocacy for SSDI, please feel free to give me a call.

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ADDENDUM February 12, 2019

This post received some feedback that I would like to share with additional information from me.

First, DCS, Inc. has a client who reports that his association with GENEX proved detrimental because it filed an SSDI claim based on Mental and Nervous conditions so that Unum could later limit benefits to 24 months. This particular client actually filed for a “physical” impairment, but GENEX filed a M&N application. The claimant found out too late because GENEX never kept in touch or informed the claimant of the Mental and Nervous filing.

“In addition, there appears to be a big problem due to GENEX’ conflict of interest for claimants over 50. In Social Security, there are various rules that allow you to get SSDI even if you have the ability for full time work.  Rather than arguing for a less than sedentary work capacity, GENEX will argue that the claimant can do sedentary or light work, but is entitled to SSDI under the “Grid” rules, knowing full well that the result will jeopardize the LTD benefits.”

In my opinion, Unum claimants should stay away from GENEX and either file on their own or hire good, competent attorneys.

Thank you to those who offered feedback. I will continue to post here as new information is received.

 

 

Claims Handlers Are NOT Your Friends And Other Nonsense

In some respects I hesitated to write this article for fear that someone would think I’m making fun. In my mind the subject is much more serious, so I’m writing about it anyway.

I received a phone call this week from someone who told me, “I don’t want to make my Unum claims handler angry at me. We’ve become friends and I wouldn’t want her to get mad and deny my claim.”

“Oh boy, here we go again”, I thought. “Another insured, persuaded into thinking a Unum claims handler (or any claims specialist) is a friend.” What I usually do in these situations is ask the insured to sit quietly for a moment and consider logically under what circumstances an insurance company who makes money from NOT paying claims could ever be characterized as “a friend.”

To make matters worse, this particular insured actually called because her “friend” at Unum is now asking she submit to a Field Visit. Some friend……

All claims handlers are trained to some extent in “playing the part.” But, in reality, most employees who touch claims are actually hired only if they are determined to be “A” type personalities who, according to one of my old managers, “won’t give away the farm.”

In addition, insureds are unaware of what’s happening behind the scenes to deny claims, regardless of what’s taking place on the telephone. This insured also told me she had not obtained a copy of her policy, nor had she read it. I asked her, “Well, how do you know you have to do a field interview?” She answered, “Because Unum cited my policy in the letter and told me I had to.” Oh boy, oh boy, oh boy………..

And, by the way, many people tell me, “I don’t want to make Unum mad at me.” Really? Unum isn’t human, it’s a corporation and can’t get mad at anyone. Even Unum can’t deny claims because it’s mad, and neither can claims handlers, who actually ARE human.

Finally, this same insured told me, “I read on your Blog that you don’t recommend using any of the website portals, but I’m going to use it anyway. I don’t want to cause any problems.”

I have to admit I don’t understand the logic of doing something you know is not in your own best interests, like speaking to an insurance rep on the phone. But, as I am frequently known to say, ” I can only tell you what I think is a “best practice”, and you will either do it, or not. The result may be that you fall into a black hole that you can or cannot pull yourself out of.” Not listening to those who know can be costly.

However, this notion that insurance reps are “friends” has got to go. Unum’s (and other insurers’) specialists are paid to deny claims, not pay them, mind you, but deny them. That doesn’t sound very friendly to me.

I also know some insureds try to “sweet talk” their way into a claim approval by sharing every family, claim, health, life, and childhood detail they can. This tactic will certainly come back to bite you.

And finally, you can’t make a sterile business entity “mad at you.” Best advice is to think logically about your relationship to the insurer which is only represented in your Plan or policy contract. This is why it is so important to read your policy and understand it.

And if what you’re thinking doesn’t make sense, it probably isn’t in your best interests. Claims handlers just want you to be cooperative so eventually you say something that can be used against you.

Of course this makes more sense than thinking Unum’s reps are your “friends.” I’d be very careful about trying to shake hands with the hyenas.

 

What Happened To All Of Unum’s Contracts And Policies And Know How?

Someone posted a comment asking me to write about what happened to Unum’s policies and contracts at the time of the June 1999 merger with the Provident Companies. It’s quite an interesting story and I’m happy to write about it. Thank you for asking the question and giving me the opportunity to write another post.

Prior to the merger, Unum Life Insurance Company maintained a “policy room” where all of the original policies and Plans were stored in library fashion. Claims specialists requested the various policies on an as needed basis and they were delivered to those who needed them.

At that time, all of Unum’s documents were still maintained in paper format, and after the policy or Plan was referred to, it was promptly returned to the “policy room.” There was never a problem in examining original policy information and as far as I know, the “policy room” system worked very well.

At the same time, policy and Plan information was also uploaded to an already antiquated system called Merlin. The pay system for IDI policies called PACE also contained detailed information about Unum’s policies and Plans, but it was an older system that often broke down when overloaded.

Most of Unum’s “dead files” and  records were transferred to microfiche and sent to warehouses at the Data Center in Columbia, SC. Once these records hit the Data Center, it was difficult to locate anything, although the microfiche could be requested and obtained.

After the merger, Tim Arnold, the new Vice President of claims came to the Portland Maine facility and had two really awful pet peeves. One, was that it appeared to him, after watching at the HOIII windows in the morning, that employee cars arriving in the parking lot late were always the first to leave in the afternoon; and secondly, that the company used way too much paper. Arnold’s pet peeve about paper began a long, disorganized transition from paper to electronic files.

One of the first decrees Arnold made was that the “policy room” was to be done away with. Although it’s unclear where the policies went, it is a pretty good assumption that they were either sent to Account Managers (sales people), or alas, they were sent to the Columbia Data Center – the point being, no one knew where the policies were making it necessary to use the old outdated Merlin to verify policy information. It was a real mess! I always wondered why Underwriting never maintained copies of all policies and Plans, but they didn’t seem to be able to locate policies either.

The company’s diary system was changed from Genesis to Navilink and paper files were done away with as files were electronically uploaded to the new systems. I can’t tell you what a disorganized, chaotic company UnumProvident was at that time. Since 70% of the claims handlers left the company (realizing they had been duped regarding the stock option awards and the 1999 People Goals) there were not enough claims handling staff to “do business.” (At the same time Unum lacked personnel, management was pushing employees over 50 and female to “voluntarily retire”, hoping to remove the most knowledgeable claims personnel out of the company peaceably.)

Realizing the company had a serious backlog of untouched claims, Tim Arnold eliminated separate product line reviews (STD, LTD, Accident, Life Waiver of Premium) and created impairment based review departments forcing claims specialists to manage all types of claims even when they had not been trained on the different products. Each claims handler had to then process all products STD, LTD LWOP etc. when they didn’t know anything about it. Again, another mess.

So, let’s recap. Arnold does away with the “policy room” and policies are not to be found while trying to process claims; paper files are eliminated and new electronic systems are in the process of uploading all files creating mega databases. Seventy percent of claim staff left the company, or were pushed out because they were tenured, female and over 50. (Women who wouldn’t voluntarily retire were eventually pushed out for poor performance.)

Arnold also sent out company wide emails informing claims handlers not to consider any medical opinions except those rendered by Unum’s medical staff. The new UnumProvident bad faith eventually resulted in the 60 Minutes and NBC Dateline TV broadcasts and the rest is history.

By 2000 the multi-state conduct market regulators were chasing Unum for its Benefits Claims Manual. When asked by Plaintiff’s attorneys about the Manual, I had to admit: “Unum didn’t have one. But, management sure put together one in a real hurry.” Although Unum submitted several training notebooks as claims manuals, the truth was, Unum never had a claims manual until forced to hurriedly put one together when called on the carpet.

Tim Arnold’s pet peeves eventually materialized into a 40 hour workweek rather than 37.5, although he still stood by the windows to watch who came in late and who left early.  I never had a beef with Tim Arnold. I presented at roundtables with him and found him to be very fair in making claims decisions as compared to Mary Fuller who frequently yelled, “Why are we paying this claim, deny it!” Tim Arnold at least gave claims a fair chance.

Finally, Arnold got really stingy about buying paper to the point that there was almost a  secret police reporting to Arnold as to who overused the company’s paper. Admins actually reported back to managers if they saw employees using too much paper!

Unfortunately, over two decades later Unum is still having difficulty locating original policies. Most policies today are stamped “Duplicate” making me wonder what DID happen to the originals, and if they were sent to the Columbia, SC warehouse and got lost. I can’t imagine UnumProvident footing the bill to have all of the policies copied, but I CAN imagine them getting lost or just pitched out.

Today, I observe that Unum’s claims handlers aren’t reading the files. It seems as though the claims people are only reading the last several months of documents. Why aren’t they reading entire files? Do claims handlers even have access to file copies? Where is all of the old file information? Regulators should start doing some Unum research to find out were the policy copies and file information really is.

In my opinion, Unum Life never survived demutualization in the mid 1980’s – a real loss of potential due to mismanagement after Jim Orr III.

From time to time, someone will ask me about Unum’s history and past, and I’m happy to share the information. Looking back, some of Unum’s history would be pretty interesting  (and funny) were it not for the fact that so many insureds were hurt by bad faith and illegitimate claim denials.

Unum might be a long way from selling life insurance to insureds crossing the Rockies during the 1849 gold rush, but unfortunately the company never walked the talk on fair and objective claim review. Once burned, the public has never forgiven Unum for its debauchery.

Now if they could only find all those missing policies…?

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ADDENDUM

Paul Revere merged with The Provident Companies, who then merged with Unum Life Insurance, to become UnumProvident. If the “policy room” containing Unum Life policies was done away with it means that no original policies from Paul Revere or Provident were transferred to Portland in paper format. Although for awhile UnumProvident sold Portland, ME as its headquarters it didn’t feel like that  from where I was sitting. It’s reasonable to assume Provident and Paul Revere policies remained in Chattanooga, TN, the real headquarters location. What policy copies left were eventually scanned in electronically, but it’s also safe to say that many original policies were lost in the translation.

Just prior to the merger UNUM Life had six offices: NYRB in New York (First UNUM) New York Regional Benefits, MARB (UNUM America also in Tarrytown) Mid-Atlantic Regional Benefits, MWRB in Chicago Mid-Western Regional Benefits, SRB in Atlanta Southern Regional Benefits, NERB in Portland North East Regional Benefits, and WRB Western Regional Benefits in Glendale CA.

At the time of the merger, where did all these policies go? Were they kept at the above offices or were they in the Portland “policy room, which I doubt. I reviewed many of the NYRB claims with First Unum policies and those were kept in New York. Prior to the merger there was Unum Life Insurance Company of America, Unum America, and Unum Enterprise. Employees actually worked for Unum America.

You have no idea how disoriented, chaotic and disorganized UnumProvident was, and remains as Unum Group to a certain extent today. Again, it’s my opinion that many original policies have been lost and claims are adjudicated using “similar” or DRAFT copies. I also question the availability of current file records because it’s clear the claims handlers are not reading the files.

The Truth About Claims Management – A Sunday Editorial by Linda Nee

Most insureds and claimants view disability insurance as “the benefits they love to hate.”  At first glance, disability Plans and policies appear innocent enough to the point that the public still puts trust in insurers to pay benefits they applied for.

However, the claims process surrounding determinations as to who gets paid and who doesn’t is a financial manipulation that entirely ignores any rational personal, or even human consideration of what medical impairment really is. Basically, disability insurance is more of a financial matter and has nothing to do with you as a person, or the fact that you are suffering from one or more medical impairments.

From my other articles, you should know that when claims are opened a financial reserve is created. The larger the monthly benefit, and longer to maximum duration, the higher the claim financial reserve is. Most claims managers and Vice Presidents have access to financial reserves and have various systems within their units that basically targets claims looking for the “biggest bang for the buck.”

The smallest working division in any insurance company is the “unit”, or “team” headed by a claims manager who is performance managed as to his/her ability to consistently meet executive financial targets. Claims managers who can’t “put up” are “pushed out” of the company. Therefore, it is very important for any claims manager to be able to meet executive financial goals. If they don’t…they’re out!

In fact, the primary goal of any unit claims manager is to meet the company’s financial profitability targets. Claims handlers who work under the unit manager are pushed, harassed, and manipulated to do whatever is necessary to “help” the managers achieve financial reserve goals. Claims handlers do not have the autonomy to make decisions on their own and must have decisions “validated” by their managers who are checking financial reserves and how badly a large reserve hit will affect profitability.

“Validation” gives managers a “look-see” and time to place claims in a pecking order of decision-making that balances approval claim reserves against denial claim reserves so that the bottom line produces profitability. More simply, managers must manipulate decisions within a specific time period so that more denials (or, reductions in reserves) takes place than approval decisions.

Therefore, from the claims manager’s perspective, it is necessary to “manipulate”, and I stress the word “manipulate”, claims approvals and denials based on financial reserves and which combinations of approvals/denials will produce target profits. We all know that at least some claims are approvable claims, but IF managers can hold up those approvals, or slide a few in once in a while amidst a rack of denials, an illusion of profitability can be created. Quite clever isn’t it? It’s frequently all about the timing.

Insureds often ask, “Why is it taking so long for Unum, for example, to make a decision on my claim?” Well, now you know. Even though Unum fully intends to pay the claim, the time manipulation has to be played out before the approval decision is actually coded into the BAS or payment system. If there have been a lot of denials coded recently, an approval wouldn’t hurt too bad, but if there have been no denials, an approval could bump a manager into a very poor performance position. All of the claims managers protect their own behinds first and foremost.

Therefore, we now know there is a great deal of manipulation taking place at the managerial levels to produce what looks like meeting targeted profitability. What this means for insureds is that decisions, even when previously made, are not timely and are often held up in the manager’s office to manipulate financial reserve profitability and show a big win for the managers.

In addition, executive management goes absolutely ballistic when the LARs are above 60%. LAR is an acronym for Liability Acceptance Rate. Premium for disability insurance is underwritten at a 60% payout rate, therefore, when claim approvals exceed 60%, it means the company is in a loss situation. Claims managers are given the word from executive management “to deny more claims”, as Cathy Liston once told her management in CBA (Claims Benefit Administration).

And, by the way, you can’t have both an approval and denial in the same  month – it’s considered a wash. If the claim is approved on January 8th, it can’t be denied until February and vice versa.

So, does it appear that there is anything about the claims process that has anything to do with medical impairment and the inability to work? What I’ve described above takes place AFTER the claim has been subjected to various reviews, meetings etc., which we also know are “stack the deck” strategies determined at “off sites” managers go to think up. In fact, these “off sites” should really be thought of as executive “think tanks” to devise more and more strategies that produce denials.

If you think about this, there are very few people who have worked inside a major insurance company who will disclose any connection between claims decisions and manipulation of financial reserves. Even when former employees are no longer employed they rarely reveal the “secrets” behind the claim manipulation.

Unum got into a lot of trouble over reserve tampering, so its response is, “We don’t do that anymore.” Yet, Unum employees who are terminated still report to me that financial reserves are well-known within the units and managers still target “the biggest bang for the buck.” Other insurers allege, “We never did that.” In my opinion, other insurers probably do manipulate reserves, they just do it in different ways; perhaps its done further up on the food chain.

When an insurer tells you in a letter, ” We want to make sure your claim receives every possible consideration”, or, “We will make a decision on your claim within 45 days”, or we have forwarded your claim for medical review (that takes 6 weeks)”, you are not being told the truth. The real truth is that the claim is probably electronically being held on some manager’s desk until the financial reserve profitability can be worked out.

The management of disability claims is much more complex than you think since I’ve only touched the surface of lack of fiduciary duty, and fair and objective claim review. Any insurance company that tells you it reviews claims fairly is not telling you the truth.