Feeds:
Posts
Comments

Friday Q & A

Q&A pointerDo Unum and the Social Security Administration share information?

Disability insurance companies are only able to communicate or share information with SSA to the extent insureds give them permission to. Generally, insurers ask claimants to sign a release giving them permission to obtain social security files. I should emphasize that claimants are NOT required to provide SSA Authorizations to insurers and can keep “the file” confidential. However, most ERISA Plans contain offset (reduction) provisions and therefore, insurers should be provided with SSDI approval letters when received.

Most insurers are only interested in SSDI records to the extent that information is received pertaining to SSDI primary and family awards (SSDI approval letters). In my experience very few insurers insist on releasing all SSDI records, and that is as it should be.

The exception, of course, is Unum. Unum sets up SSDI schemes to not only obtain SSDI files but communicate with SSA’s DDS’ (Disability Determination Specialists). Unum sends out their own versions of an SSA Authorization that when signed, releases Form 831. Unum’s SSDI Authorization is also valid for two (2) years when there is no valid reason for Unum to be requesting SSDI formation for that long. Form 831 provides the name of the DDS, as well as the code listings under which SSDI was approved.

I’ve also been told that Unum’s claims reps are instructed by managers to attempt conference calls with claimants and SSA by phone so that the claimant can get Unum’s reps past the phone menus and directly to the DDS. This is entirely inappropriate, and claimants should be on guard not to agree to this nonsense.

Claimants are required to provide insurers with copies of  SSDI approval or denial letters so that offset and overpayment information can be obtained. In addition, claimants should not provide any insurer with SSDI letters resulting from an Administrative Law Judge decision. These letters inform recipients of favorable decisions, but often provide a great deal of information that companies such as Unum can misrepresent to deny claims. Letters from ALJ decisions are NOT official approval letters and claimants should wait to receive the approval letter before sending on.

Unum caused UK recipients of government welfare programs a great deal of pain and suffering by interfering with government entitlements in Great Britain. Although Americans often see the word “welfare programs” and freak out, in reality work and health welfare in the UK is supported by taxes the same way SSDI is here in the US.

It appears to me that Unum is in the process of “assisting” SSA who is really entitled to benefits and who is not. This can be seen by the increase in frequency that SSA is now “updating” files.

The last thing Americans want is Unum interfering, or involved with the only entitlement program Americans pay for through FICA taxes.

I am being harassed by Unum to apply for dependent SSDI benefits. Do they ever let up?

In the “Other Monthly Income” section of most Unum policies, Plan provisions provide for offsets (reductions) of benefits for not only benefits received, but benefits entitled to. This means Unum can reduce benefits with estimated offsets for SSDI awards claimants aren’t even receiving yet. My suggestion is to apply for both primary (you) and family (dependent) SSDI benefits at the same time and get it over with.

The Hartford recently harassed a claimant to apply for dependent coverage by phone and sent frequent letters. Insurers will continue to harass you until they have recovered every penny Plan policies entitle them to. Unum seems to have a current focus going on forcing claimants to apply for dependent coverage. Claimants who want to avoid possible offsets for estimates of dependent coverage should apply as soon as possible to avoid harassment.

Why is Unum forcing me to apply for SSDI when I intend to return to work?

I recently had an opportunity to watch a YouTube video of House Representative Trey Gowdy (R-SC) hammering a SSA judge for overturning 90% of SSDI claims at the ALJ level. Representative Gowdy’s points involved “costing the American taxpayer” for people who could work. I thought at the time that Rep. Gowdy was about as far away from the real reason for the bankruptcy of SSDI as he could get.

Years ago, I was an expert witness in a qui tam case Loughren v. UnumProvident when it was proven Unum indiscriminately forced all ERISA claimants to apply for SSDI and cost the American taxpayer millions in administrative and benefit costs. The case was won, but only marginally so. The real cost to the American taxpayer is probably in the millions.

Technically, insurers should only require claimants to apply for SSDI when it becomes apparent after 24  months of benefits that they are totally disabled and meet the criteria for SSDI. However, insurers rarely wait 24 months to determine if claimants are able to return to work, and literally “force” claimants to apply under threat of “estimate reductions” from benefits.

In my opinion, group insurers often shoot themselves in the foot by forcing able-bodied future workers to apply for SSDI. Return to work programs are just as profitable as pushing claimants to apply for SSDI. Generally, once claimants receive SSDI they are not likely to give up the benefits even if they are able to work in some capacity.

Who do you favor in the upcoming presidential election?

The purpose of this blog is to provide information relative to private disability claims. I choose not to discuss my personal political views on this forum. Even if I did exercise my right to a public opinion it is likely, as many YouTube Commentaries and bloggers have already experienced,  this blog would be censored.

Therefore, I have chosen to restrict this blog to disability issues for the betterment of all.

dont-poke-the-bearOne of the things insureds and claimants often get themselves involved in is “ranting, raving and arguing” with insurance companies and their representatives.

Due to the fact that the disability claims process is complex and frustrating, some insureds become so angry they feel the need to debate every insurer issue/request to a fault. Letters go back and forth from claims rep to insurer, but no issue is ultimately resolved. Insureds suddenly find themselves on an eternal merry-go-round using repetitive arguments in an attempt to resolve infinite circular issues. It doesn’t work, and is a major waste of time!

Attorneys also find themselves riding the merry-go-round balancing “getting information into the record” without creating new red flags insurers had not thought of yet. Not every claims issue is a “legal matter”.

In fact, most claims issues are administrative in nature until an unwise attorney pushes his weight around and turns a very simple request into the potential for the “Scopes trial of the century.”  [State of Tennessee v. John Thomas Scopes] In my opinion, attorneys also have a conflict of interest between acting in the best interests of the client versus how to get the most money out of the case.” From a claims management perspective attorneys often create more red flags than they resolve, pushing cases into litigation for no reason.

What worries me is that the “rant, rant, rant” methodology of defending disability claims often opens doors to insurance red flag issues insurers never would have thought of if insureds had not mentioned it first. Insureds and claimants ALWAYS over speak their claims when trying to convince insurers claims are legitimate. Clearly, choosing to argue over every normal and customary request “pokes the hibernating bear” and puts YOUR claim at the top of the denial list.

Every written communication to disability insurers should be wrapped around issues involving contract provisions. Insureds would do well to remember that the only relationship that exists between insured/insurers is written in the policy contract or Plan. Citing policy and Plan provisions in defense of a disability claim is impossible to do when insureds and claimants haven’t obtained or read a copy of the document.

If an argument isn’t specifically identified in the Plan or policy document it is most often an insurance internal administrative pattern of practice that insurers attempt to enforce as if it were a contractual matter. Most ERISA Plan documents contain language that requires claimants to submit “other information” such as responses to questionnaires, Claimant and Physician Statements – not worth arguing about. I regard these requests as “normal and customary” and claimants should cooperate by “responding in like kind”, meaning answering only what is asked, or providing only what is requested.

Ranting, and arguing without citing contractual support or provisional language is punting in the wind. Normal contractual requests for information should be “reasonable” and “contractually supported” whether the insurance company raises the issue, or the insured.

Advanced degrees, professional stature, medical or legal training does not suddenly make anyone an expert in disability claims management. I generally tell callers, “Disability claim denials are an equal opportunity occurrence” and higher education does NOT an expert make.

In my opinion, insureds who presume higher knowledge about claims due to higher educational status often open the door to a “lion’s share of investigation” because they present themselves to insurers as “educated”, but manage their claims in opposition to their own best interests. I can’t tell you how many times I’ve received calls from highly educated insureds who have misinterpreted policy provisions and have already attempted to defend invalid arguments with insurers.

The point is, do you really want to poke that bear? Insureds and claimants always have the right to defend their policy/Plan/claim and submit information to the record or Administrative file. But, there is a right way to defend policy issues without ranting, raving, and causing red flags in the review process that never seem to go away.

Attorneys who also manage claims should not presume to invoke “legal arguments” for normal and customary update requests. There is really no need to do that.

Insureds and claimants often have much more successful claim outcomes by leaving the hibernating bear alone and only responding to specific questions asked or raised. And then, responses should always include citations of policy provisions that support your point of view or defense of your claim.

Hungry VultureThis is a reminder that insurers have been gearing up for 3rd Qtr. profitability results and may between now and September 30th deny claims without legitimate justification.

Claims currently under investigation due to prior IMEs, field visits etc. are now undergoing scrutiny to determine if insurers can get away with unsubstantiated claim denials. In general, claim denials after the 15th of this month were targeted for profitability as of the end of September.

Companies known to engage in profitability targeting include Unum, Prudential, Aetna, CIGNA, The Standard, Reliance Standard and Sun Life. Although Mass Mutual is a mutual insurance company, its internal claims management is gaining momentum parroting the companies listed.

Insureds and claimants should keep in mind that profitability “targeting” denies the right to full, fair and objective claims review and is a well-known unfair claims practice.

Complaints(Reposted with commentary from consumer affairs.com)

Loretta of Maple Shade, NJ on Sept. 8, 2016

I’ve been an RN Case Manager at Hahnemann Hospital, part of Tenet Healthcare, since September 2003. I have had to use the Unum disability insurance (the only option we’re provided with) for any medical leave since being hired, and have had many more negative interactions than positive ones. I have had chronic back pain since an MVA in 1991, which I was desperate enough to make go away that I agreed to a 2-level spinal fusion in 1/2003 (even though I knew there was a really good chance that it wouldn’t help!). I was right, it didn’t help, and when I tried to get my employer (Horizon Blue Cross of NJ) to set me up to work from home (which other nurses doing my same job were already doing! ), she instead fired me for being absent! I started working at Hahnemann a few months later.

Since 2006, I’ve had to misfortune of having to use Unum multiple times for short-term disability, and I’ve had problems with my payments for more half of those periods of disability. Since I returned to work after all but present episode, I was eventually able to start bringing in money again by returning to my job. This time, however, I’m in a different position. I’ve been getting treated for osteoarthritis in my knees, hands, wrists & fingers for years. At this point, I’m no longer able to tolerate hours of computer, mouse, charting & writing anymore, and & meds I’ve been taking all these years make me a little drowsy, leaving me in danger of being fired for sleeping on the job!

I didn’t receive the check for the initial 6 weeks I was out (which included a 2-week elimination period that I was paying extra to reduce from 4 weeks) until AFTER I was initially scheduled to have returned to work! I was the one who put the paperwork into the fax machine at the doctor’s office for the first 6-week extension of my leave. I gave them a few days to work on the records, and then discovered on the website that they had closed the claim! I called them, and went back to the doctor’s office to resubmit everything to them through the end of July, and waited again for something to happen. Nothing did, so again I called, and uploaded the chart info myself to ensure they couldn’t deny receiving them.

The day after the records were uploaded, Unum generated another letter again asking my doctor for his records. When I called to tell them that both the office & I had submitted the requested information. I was then assured that the information was received & was being reviewed. Today, I dropped off my prescription for my pain meds and found out that my health insurance, which I sent almost $1,300 to Tenet to keep intact just after receiving the payment from Unum for June, 2016 (that I didn’t receive until the last week of AUGUST!). I have to now deal with the Tenet benefits department to see if there is anything that I can do to get this mess fixed.

My doctor wonders why my normally average blood pressure has gone into the stroke (200/100) range! The people at Unum have no conscience; they’ve received specific notes from my doctor noting that my blood pressure has been too high for him to give me steroid injections in the joints in my fingers, which has not happened to me before this summer.

(DCS has never recommended the use of Unum’s Internet portals or apps. To begin, it’s our understanding there is tracking software there, but my major objection is that it is unclear whether any activity taking place on the portal is actually placed in the Administrative Record or file. In addition, Unum’s customer service is extremely poor. I do not recommend using Unum’s website portals or apps. It’s a recipe for administrative disaster.)

Edris of Freeport, NY on Aug. 30, 2016

I had major stomach surgery 2 months ago and under my doctor’s orders was scheduled to be out for 6 weeks. Unum paid my claim for 4 weeks and decided that they were not going to pay for my additional 2 weeks because I was able to go back to work. Who the hell do they think they are?? If my doctor says I need to be out, an insurance company, who does not know me or my circumstances has no right to deny my claim!!! I have just filed an appeal and I am waiting to hear back. If the claim is denied again, I am calling my attorney. Unum is an insurance company, not a team of surgeons who know what a patient needs. My company and I pay money into the insurance company for my STD… It’s not their money!!

(Unfortunately Unum still uses MDA, a desktop medical recovery period data base that provides claims reps with estimated periods of recovery. Any software data base available today shouldn’t be used to make decisions that involve financial reserves and profitability. I can understand that perhaps MDA might give Unum’s medical staff some guidance, but using the software to deny claims using standard recovery periods for all insureds and claimants is an unfair claims practice. Each individual’s medical situation is different and claims decisions should be made considering the recommendations of medical treatment providers.

Unum was a great supporter of ATOS, a similar data based used exclusively in the UK (without human intervention I’m told), and it was a disaster in that the decisions made by ATOS, the computer, actually resulted in the death of persons entitled to welfare benefits. Anytime Unum intervenes to set up claim review systems, it is usually a scheme to make more money.)

Kim of Tyrone, PA on Aug. 27, 2016

I have it for short term and as a supplemental insurance! I pay 86.00 a pay for supplemental and they deny to pay claims and they take 2 weeks plus to pay. Please please do not purchase this insurance, you will have nothing but heartache! I had bilateral hand surgery, they refuse to pay for the second surgery. Lucky before I had them done I called and they told me they would pay for both hands, so since the phone call was recorded they had to pay!! Then my last week off work they would not pay me cause (even though the doctor said I wasn’t able to return to work) they refused to pay my last week off!!!

(This sounds like Unum’s STD management and the use of MDA to cut off people’s benefits in accordance with standardized recovery periods in the MDA data base.)

Greg of Quakertown, PA on Aug. 18, 2016

I had an accident which caused head trauma. At the start Unum paid the claim. My doctors and specialists all said that I was unable to work in letters to Unum. About 3 months in, Unum stopped paying claims. They stated it was under review by their doctors (who never saw me). After 90 days, they ruled against all doctors that were treating me and said I could work. Which was funny because I had to have help doing just about everything. So I appealed; 90 more days, then they said they needed another 90 days. Appealed denied. Hire an attorney before 2nd appeal. The story quickly will change from Unum.

(It is getting to the point that it’s clear to the general public at large that Unum is now the company of “NO”. Nothing has changed since the Multi-State Settlement Agreement and Unum continues to abuse its discretion in nearly every way it can. Employees need to take this information back to employers with requests to change Plans at the next annual enrollment period. If employers refused to buy Unum’s LTD products, the company wouldn’t be able to stay in business very long.)

N. B. of Plano, TX on Aug. 16, 2016

I had to go out for a major surgery and my company uses UNUM for their short term disability. I have never had such a horrible experience with a company. This is my first time ever going out on STD in my life and this company has badgered me, harassed me and made my recovery stressful. The doctor has specifically stated that the “full” recovery for this procedure is 6 weeks. The doctor has provided them with every document they need to support my claim.

Now, according to their “chart” my recovery is only allowed for 4 weeks and they just sprung thus surprise on me today, now I have less than a week left before I go back to work. My representative, Tracy is horrible. I can never get on touch with her, and when I opt out to a Tissot speak with someone, nobody knows what is going on. Thus company is deceitful and under no circumstances does your representative try to help you. I’m still on pain meds and cannot drive. Not only that but, since my surgery was on my stomach, it’s still swollen and I cannot wear anything with a waistband for longer than 2 hours. But, according to their chart, I’m recovered and need to report back to work.

I’m not trying to work any system or take advantage in any way, but I do feel like they are trying to screw me and I have to “prove” that I’m not able to work. This company and every associate I have dealt with is horrible… Especially Tracy put of Portland,ME. When I asked to speak to her supervisor, she says she wasn’t allowed to give put her information but I can call the 800 number and ask for Sheryl. Why would the supervisors isolate themselves like that? Or, why would Tracy lie? If you need rest in order to recover from anything, don’t expect it when you deal with UNUM.

(This situation is terrible and I’m sorry you had to go through all of this. Again, Unum is obviously using MDA to determine standardized recovery periods, and it’s unacceptable. I agree that Unum’s claims reps are unprofessional and rude. Unum claims reps are the bottom rung of administrative review, do not have autonomy to make claims decisions, are harassed by their managers to deny more and more claims, and generally are so stressed out they may not realize what planet they are on.

Unum’s claims reps also shield their Managers and Directors from customer contact. I wonder at times if Unum’s claims reps really “get” the fact that they are used by the company as a buffer to safeguard Managers and Directors from information that may be discoverable. Although Unum claims managers have knowledge of financial reserves and use that information to make claims decisions, claims reps do not have access and therefore can deny any prejudicial conduct based on profitability. Unum’s claims reps are no more than glorified Administrative Assistants and that probably makes them more contentious than ever! In any event, Unum’s conduct and that of its representatives contributes to Unum’s horrific public reputation.)

ERISAUnum’s mantra has always been to remove DI policy jurisdiction from state court to federal court, or more specifically to ERISA. Requesting that a judge rule that a Disability Income policy is subject to ERISA removes the opportunity of bad faith rulings, punitive damages, and limits administrative decisions to standards of review such as “arbitrary and capricious” and “abuse of discretion.”

The State of California included Unum’s propensity to remove DI policies from state jurisdiction as an unfair claims practice. Recent information to DCS suggests that Unum continues to attempt to litigate state jurisdictional contract cases under ERISA in federal court. If Unum gets the right judge, the change in jurisdiction is a possibility.

In an effort to assist employees, employers often with all good intentions, create internal procedures to collect premiums on behalf of employees even though there is no employer provided Plan per se, or group policy. Employees purchase their own DI policy through one insurer, such as Mass Mutual, and employers deduct premiums as a benefit to employees. Payroll plans do not exclusively make policies subject to ERISA.

I am not an attorney and do not profess to be an expert on ERISA. However, the following link is the best resource I’ve found if you are interested in knowing whether a policy is subject to ERISA or not.

http://www.buchanandisability.com/helpful-resourcesandarticles/how-to-tell-if-an-insurance-claim/

The point of this post, however, is to inform insureds that Unum’s attorneys frequently attempt to remove DI policies to federal court as a “pattern of practice” in order to place DI insureds at a disadvantage particularly if bad faith is involved.

Unum never seems to quit with the schemes to benefit itself at insureds’ expense.

 

Breaking newshttp://www.prnewswire.com/news-releases/cathy-liston-appointed-to-lead-sun-life-financials-us-group-and-voluntary-claims-practice-300306723.html

In my opinion, wherever Cathy Liston is isn’t good news for claimants.

calculateHere is an excerpt from my book, “Successfully Managing Private Disability Claims” to be published in early 2017. I know that this can be a tough subject to understand, but I have been asked over the years how to calculate “indexed” figures relative to disability policies – mostly by attorneys. The calculations are actually pretty easy once someone (like me) tells you where to look for the indexes and how to apply them. This subject has been a long time in coming.

One of the most misunderstood calculations dealing with disability claims is the “indexed pre-disability earnings” definition using indexing that is only used in three distinct policy situations:

  • To determine whether new applicants have at least a 20% earnings loss (if indexed pre-disability earnings is mentioned in the Plan or policy).
  • To calculate “residual” or part-time earnings and benefit amounts.
  • To determine “gainful” alternative occupations as part of an “any occupation” investigation after 12, 24, 36, or 60 months change in definitions.

“Indexing” is NOT a Cost of Living Increase, but is frequently misidentified by insureds and claimants as one. Caution should be exercised not to confuse “indexing” with COLA policy calculations because they are not the same thing.

The Glossary of most group Plans define indexed monthly earnings as:

INDEXED MONTHLY EARNINGS means your monthly earnings adjusted on each anniversary of benefit payments by the lesser of 10% or the current annual percentage increase in the Consumer Price Index. Your indexed monthly earnings may increase or remain the same, but will never decrease.

 The Consumer Price Index (CPI-W) is published by the U.S. Department of Labor. [The insurance company] reserves the right to use some other similar measurement if the Department of Labor changes or stops publishing the CPI-W.

 Indexing is only used to determine your percentage of lost earnings while you are disabled and working.

Most insureds, claimants and insurers ignore “indexing” and rarely perform the calculations correctly. I am aware that the concept and calculations may be confusing to some, but the subject of “indexing” does merit explanation in any book about disability claims.

The Bureau of Labor Statistics (BLS) publishes the Consumer Price Index of Urban Wage Earners and Clerical Workers (CPI-W) on a monthly basis. The CPI is a measure of the average change over time in the prices paid by urban workers for a market basket of consumer good and services representing approximated 89% of the total population.

The Social Security Administration also uses the CPI-W to adjust benefits paid for SSDI, SSR and SSI income recipients.

            The CPI-W index chart is located at:

            http://www.ssa.gov/OACT/STATS/cpiw.html

Most of us are aware that most goods and services cost more today than they used to. The increase is often referred to as a “cost of living index” which is why some insureds and claimants confuse indexing with COLA. Nevertheless, the ultimate result of “indexing” takes into account any inflation that has occurred over time.

 The Bureau of Labor Statistics uses the years 1982, 1983, and 1984 as a base line of 36 months and assumes the average of these years is equal to 100 or when the value of $1 was valued at 100 cents. For example, a current index of 120 means there has been a 20% increase since the baseline, and an index of 80% shows a 20% decrease since baseline.

Although “indexes” are documented as ratios, they are often converted to percentages of increase from one year to the next.

For example:

Year 1                       Index was 112.500

Year 2                       Index was 121.500

Change                     121.500-112.500= 9.0

% Change                 9.0/112.500 x 100= 8%

Another example:

Year 1                     Index was 225.000

Year 2                     Index was 243.000

Change                   243.000-225.000=18.000

% Change              18/225.000 x 100=8%

The above cited definition of disability states, you are disabled if, “You have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury.” Let’s take a look at how this should be determined.

Employee A became disabled on July 1, 2015. At that time his annual salary just prior to his date of disability was $65,500, or $5,458.33 per month. After his date of disability, Employee A must show at least “an indexed 20% loss in monthly earnings” calculated as follows:

CPI-W Index for July 2014 was 234.525 (From chart for year before date of disability.)

CPI-W Index for July 2015 is 234.789 (from chart)

Change in index = .264

% Change = .264/234.525 x 100= .113%

Monthly indexed earnings = $5,458.33 x .113% = $6.17 + $5,458.33 = $5,464.50

Calculated 20% of indexed monthly earnings: $5,464.50 x 20% =$1,092.90

An easier way of looking at this is to say that Employee A must have been unable to earn greater than 80% of his indexed monthly pre-disability earnings of $5,464.50, or $4,371.60/month. ($5,464.50 x 80% = $4,371.60)

It is important to always compare “apples to apples” so to speak and use monthly pre-disability earnings figures rather than yearly ones.

The advantage of “indexing” monthly earnings gave Employee A an monetary advantage of $6.17, taking inflationary purchasing power into account, before calculating the required 20% earnings loss.

Admittedly, the United States economy has not experienced great inflation in the last 10 years or so, in fact, we’ve experienced recession, the opposite of inflation. Therefore, the advantages of indexing are not significant, but it could make the difference between receiving a benefit and not receiving it.

Likewise, when claimants return to work and have earnings, or undergo any occupation investigations, indexed figures are used. Because indexing involves “changes in percent increases” indexing can only be applied to claim situations after the first anniversary of benefit payments. However, determining the initial 20% monthly earnings loss for the purpose of meeting the definition of disability is, of course, the exception.

As I indicated earlier most claimants including attorneys often disregard “indexing” due to the perceived complexity of figuring it out. Still, when the policy definition of disability states, “20% loss of indexed monthly earnings”, it’s a good idea to put pencil to paper and verify that you do indeed meet the definition as written in your policy.