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Med MenIt’s well-known in the insurance industry that insurance medical review is a “turkey shoot” with fewer than 30% of reviews supporting disability. Although some insurers front the cost of buying board certified credentials (Unum), most other insurers outsource medical files to physicians who specialize in insurance review and documentation supporting return to work. Unfortunately, insurance medical reviewers have well-earned their poor reputations as “physicians who trade ethics for money.”

What is of continuous interest to me is how insurance physicians misrepresent medical patient information that screams total disability. On occasion, I often wonder if the reviewing physician actually read the same medical records as I just did. In addition, industry physicians “snatch” words and phrases favorable to them at the expense of all else in the record favorable to insureds.

Fact: “Insurance medical review deliberately misinterprets medical information for the intended purpose of discrediting disability claims at the expense of insureds for profit.” They know it, we know it, and insurance regulators know it.

State insurance regulators could perform conduct market examinations comparing internal medical reviews with actual patient notes reviewed. It would become immediately apparent that insurance medical write-ups are contrived reports of misrepresentation of insureds’ realistic inability to perform work full-time.

Although it makes perfect sense to review actual files, state regulators who are influenced by political insurance lobby groups, turn blind eyes to insurance bad faith. Apparently, it isn’t profitable to ruffle the feathers of large corporations operating in the various states.

A typical example would be the Maine Department of insurance who fails to enforce the multi-state settlement amendments requiring Unum to consider the opinions of treating physicians. Unum not only deliberately discounts all medical opinions other than its own, but sets up insureds with multiple hierarchies of medical review to reinforce unjust medical opinions via the number of reviews.

If the insurance regulators of Maine, Massachusetts, and Tennessee were to enforce the RSA Unum may be found to have violated the agreement. There are additional monetary fines Unum would have to pay if found to have violated the agreement. In my opinion, all regulators need to do is look for Unum’s bad faith and they will surely find it. The problem is, no one’s looking.

Companies other than Unum will pay medically supported claims by treating physicians, but Unum stands alone as the only bad faith insurer who still discredits all treating physician’s opinions and misrepresents medical information in its own favor. This fact alone may give you some idea of how profitable “dirty” insurance medical review is.

One of the women who actually appeared on the 60 Minute Unum expose described a process whereby claims handlers could choose which Unum physician to present claims to because it was known they would deny certain claims. I actually did the same thing as a Unum employee since I also found most Unum physicians could be persuaded to document anything.

Insurance medical review is not intended to represent fair assessments of medical impairment, but rather to present already documented medical information, lab reports and patient notes in a convoluted, misinterpreted manner to support business decisions that have already been made to deny claims.

Insurance medical review is unfair at its core and is openly recognized as such by those in the business and in the know. Insureds may be asking themselves why insurance companies are allowed to engage in such practices which over time become “patterns of practice” also known as racketeering.

Internally controlled medical review is the primary demonstration of discretionary authority insurers have to control who gets paid and who doesn’t thereby controlling their own profitability levels. In fact, disability insurers would not exist if they were suddenly not allowed to engage in prejudicial and biased medical review.

Insurance “Med Men” essentially guarantee that insurance companies maximize profits regardless of any harm caused to insureds who have paid premium for many years. In light of how the process works, I often wonder why professionals continue to buy disability insurance at all.

Insureds should always realize that internal medical reviews are not intended to be fair assessments of  medical impairments or ability to work. Simply put, insurance medical review, whether conducted internally or outsourced is a means to an end for the purpose of maximizing profit at the expense of insureds who look to insurers to assume the risk of disability.

In reality, the “risk” of having to file disability claims is transferred back to insureds who risk not getting paid at all.

Thanks to the insurance “Med Men” who support unfair claims review, insurers are continually allowed to profit from their own criminality.

A Quick Pin It!

Pin itInsureds spend far too much time trying to change what insurers do when in fact nothing can change the already firmly established protocols of internal claims management.

Nothing insureds say, do, whine, rant or dispute will change procedures directed by management; and engaging in multiple requests to restrict activities of any insurer creates “red flags” insureds may later regret.

The only control insureds have over the management of their disability claims is to change how THEY do things in working with treating physicians and providing updated paper work and information.

Requesting all communication in writing is a necessary first step in maintaining control over the flow of information. Remember, insurers cannot hold against you what you do not say.

Maintaining good communicative relationships with treating physicians is also important in making sure you have an opportunity to view completed forms and other paperwork before it is faxed to insurers. Medical information without specific “restrictions and limitations” is useless to support disability claims.

In the end, insurers are “going to do what they’re going to do”, but you, on the other hand, can take the necessary steps to ensure the accuracy and completeness of what is being sent to the insurance company now.

Insureds who attempt to control the internal claims procedures of insurers generally regret it in the future. Insurance companies aren’t going to change what they do and most requests from insureds wind up on a “pay no mind list.”

The best course for insureds is to make sure they are knowledgeable and are taking all the necessary steps THEY can to place information in the record that makes it more difficult for insurers to deny unjustly.

Constant attempts to convince claims handlers to do things your way is not a winnable conflict and only adds more confusion, anger and frustration to the claims process. Those insureds and claimants who focus on their own actions with respect to claims are the most successful.

Several articles concerning an IME physician used by Reliance Standard.

http://caselaw.findlaw.com/az-court-of-appeals/1365412.html

http://www.amednews.com/article/20090810/profession/308109972/5/

mergerWhenever a corporate changing of the guard takes place it usually signals an operational or organizational change including possible mergers with other companies.

In March of 2011, authors Zachary R. Mider and Jeffrey McCracken reported merger negotiation talks between Unum and Sun Life Financial. Although the negotiations broke down in 2011 because Unum insisted on too much executive power, the recent replacement of Tom Watjen with Richard P. McKenney, a former executive vice president of Sun Life Financial leads me to believe future mergers may actually happen.

In 2011 Tom Watjen, CEO of Unum Group told audiences “we kiss a lot of frogs, but we haven’t done anything yet.” At the time, a merger between the two companies may have seemed a good idea. Sun Life, searching for more US business and Unum looking to true-up its profitability in poor economic times seemed a likely match, but it just didn’t happen.

Unum’s philosophy to pay as few claims as possible was clearly explained by CEO Watjen:

“People need to recognize we’re not a health care company,” he said. “We work with employers to get people back to work, and getting that through Congress is a challenge.”

In fact, Watjen said, companies like Unum actually help people “take responsibility for themselves and their families, and take pressure off the federal programs” in a time of shrinking wages and work forces.

(“Take responsibility for themselves and their families” is the Unum buzz word for “self-insuring your own disability or going back to work.”)

Nevertheless, appointing another former chess piece from Sun Life,  Richard P. McKenney as CEO may be a message of changes to come. Merging two of the worst disability insurers in the world will be a deadfall for those who depend on benefits in times of need.

Americans who still believe in the American dream of a democratic republic should read this article very carefully.

http://mobile.nytimes.com/2014/06/27/technology/facebook-battles-manhattan-da-over-warrants-for-user-data.html

YellingAs a disability claims consultant I can certainly understand how it could happen that insureds become so angry and frustrated with the claims process that they can’t see anything else except to “make them pay” and “admit everything they’ve done to me.” Although “seeing red” when it comes to managing a disability claim is a common reaction to abuse, anger, rant and non-cooperation doesn’t move claims forward at all.

The fact is, the disability claims process IS frustrating, harassing, and comes at a time when insureds aren’t feeling well and find it difficult to put up with claims handlers who just won’t pay claims. Unfortunately, once insureds really get angry, everything insurers do or say becomes suspect and the claim falls into what seems like a bottomless pit of going nowhere.

Some insureds actually act counter to provisions that specify their obligations to meet criteria of Plans or policies. Not too long ago DCS was forced to fire a client because he refused to arrange to go to an IME despite our recommendations that he should go. This particular insured also did not provide the insurance company with the “whole truth” and therefore I could not continue to assist him. The reason? According to this insured, the insurer (Northwestern Mutual) was dishonest and was trying to “trip him up.”

In addition, we’ve come across some claimants who suspect everything, demand repeated proof, and accuse insurers of “lying”, and engage in “letter wars” that also gets them no closer to claim decisions. Most of my readers know I would be the first one to tell you that disability insurers are dishonest and delay or deny payment of claims. At the same time, constantly arguing small “who done it” points is trivial and in general puts insureds on a merry-go-round they can’t easily get off of.

Although insurers should base their investigations and opinions only on the unique facts of claims, there is credibility and “appearance of honesty” suspicions that arise referred to as “red flags”. Constantly contacting claims handlers (remember we do not recommend communicating by phone), and arguing, or engaging in “letter wars” isn’t productive to the claims process and will most likely produce denial decisions.

Therefore, while I validate anger reactions of insureds and claimants to the disability claims process, I certainly do not recommend engaging in constant rants with insurers. Recently, a new client came on board with major issues concerning Guardian. By the time he made a call to DCS he mistrusted everything the company did to date, had not been paid, and was in tears during most of the call.

During our conversation he reiterated that he wanted “proof” of this, and “admission of wrongdoing”, and “statements in writing” etc. It also became apparent during the call that his impairment was due to Bipolar and cardiac issues. One thing was certain – he was so mistrustful of Guardian and had been harassed to the point of desperation by the time he contacted DCS that his only motivation was to “make them pay for what they did to me.”

The unfortunate missing part, however, is that this poor insured still had not been paid benefits due to him. Within several days, DCS was able to work with the insured to the point that together we were able to support his claim medically, and he received a $40,000 check in the mail. I could not get him to stop crying.

In this case I think Guardian brought most of the anger and suspicion upon itself by demanding a field interview with both the claims handler and a field investigator (Guardian calls them “Technical Consultants?’) showing up to ask questions of someone diagnosed with Bipolar Disorder. Of course, this interview wasn’t going to go well and it didn’t. This is an example of what I mean when I say, “disability insurers know very little about disability.”

Also, well-intentioned, but inaccurate information provided by friends and neighbors can also incite one to wrath and isn’t always helpful either. Insureds who file disability claims need accurate information about the claims process, not opinions from those who really aren’t “in the know.”

Instead of acting upon anger, overreaction and suspicion, insureds and claimants should be more focused on “solving the problem” which in most cases is “paying the claim.” Insureds who find it difficult to calm down and act accordingly could benefit from having a consultant sort through what’s needed and getting the job done.

In any event, ranting and arguing with insurers doesn’t result in timely payable claims. Again, although I validate the feelings of anger and frustration with an impossible claims review process, I do not recommend constant suspicion on the part of insureds that makes them appear uncooperative, and out of control.

Pop Goes the weaselJust a quick reminder that Murphy’s Law will be in play this weekend since insurers’ investigators will be out in droves conducting surveillance of unknowing insureds.

Insurance investigators will be watching at the lake, family gathering, fireworks displays etc. attempting to “catch” insureds exceeding medical restrictions and limitations in any way possible. Although it’s tempting to push the envelope of medical ability on a holiday, it’s probably not worth losing your claim over.

DCS would like to remind our readers that medical restrictions and limitations reported to insurers should be abided by on holidays as other days. The old-time response of, “Well yes, I did ride that water ski, but I suffered for a week after ward” doesn’t fly with insurers.

Please have a good time with family and friends this 4th of July, but also safeguard your well-being within your medical restrictions and limitations and don’t push the envelope to the claim denial line.

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