It’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.