Unum – Oh, Boo Hoo Hoo!

On August 11th I wrote a post titled, “Unum’s Paranoia About Recording Calls”. (Please refer to the original post.)

However, as part of the continuing saga, apparently Unum was so upset about its own recording calls allegations that it contacted the claimant’s employer who proceeded to withdraw its support of the claim and claimant!

I spoke to the claimant yesterday who proceeded to tell me, “My employer says I’m in a lot of trouble”, he reported. “How do I prove I actually didn’t record anything? Now, my claim is in jeopardy, and my employer is mad as hell.”

If you recall, Unum insisted the claimant sign a statement that he will never record a call ever again, and provide Unum with a copy of the alleged recordings. I have to ask myself what Unum is so scared of that it has to threaten its insureds/claimants to NOT record calls. Is Unum recording calls? Its voice mail message says “calls may be recorded.” Which calls? Can the insured obtain copies of all calls recorded by Unum?

It almost seems incredible to me that we have a major insurance company acting like an unprofessional spoiled brat. This is one of the reasons why I always recommend “in writing” communications only.

Come on, Unum. Your claimant told you he didn’t record anything, why don’t you just move on and play nicely on the see-saw.

 

 

Unum – Keeping You Engaged – And Busy

As a Unum insured have you ever noticed that there seems to be no end to the letters, requests and phone calls you receive? As soon as you send in what Unum requested, within 30 days there’s yet another letter or phone call? The concept of keeping insureds and claimants “engaged” is required of all claims handlers in one way or another.

One of the worst situations claims management has to contend with internally is that of having a “backlog of untouched claims.” Viewed as lost profits and lost opportunities for denials, backlogs can literally cost insurers millions. In order to control/prevent outlandish backlogs of unreviewed claims, processes are put in place that requires claims handlers to “touch” claims at least every thirty days. Employee performance is then evaluated to determine whether or not claims handlers can in fact manage the 250 or so claims they have in their “block.”

Unum’s process includes a series of “flups” (follow-ups) created on the Navilink system that continuously shows next steps on the “primary plan” deemed appropriate by the claims handlers or roundtable reviewers. Each day, a list of flips shows up on the handler’s desktop, basically representing work for that day. Failure to take action on a “flup” and setting a new one is cause for termination.

So says, one Unum terminated employee who shared with me she was fired and accused. of not “taking care of a flup” while documenting that she had. Oops. This can easily happen in the course of a day and a few hundred flups, but Unum’s managers take this sort of thing seriously.

The ultimate result of continuously requesting information is to keep insureds/claimants constantly reminded of where they are getting their money from and who has control over it. Frequent requests for information, phone calls, and harassing patient records requests keeps insureds stressed out – and BUSY. Claims handlers are always “in touch”, or placing insureds on their fetch list every thirty days.

Even with taking care of daily flups it is possible for claims handlers to have backlogs. Managers keep a stern eye on the chasing of information from insureds with continuous reminders, checks and threats of termination when backlogs aren’t managed well.

Again, from the insureds perspective, receiving constant letters and phone calls from insurers is harassing to the point of creating anxiety and depression. This is yet another supportive argument for not speaking with Unum on the phone. At least the phone calls seem to come to an end when you put a stop to it.

The concept of insurance “Risk Management” involves the 1)assessment of the claim and setting a “primary plan direction”, 2) identifying the probable outcome (denial), 3) reviewing steps to bring about the planned outcome, and 4) controlling what requests need to happen to bring about the desired result.

Nothing inside a private disability insurance company happens by trial and error. Assessing, identifying, reviewing and controlling is at the heart of any claims review process, not only at Unum, but other insurance companies as well.

Nevertheless, if you’ve ever wondered why you keep getting multiple letters, phone calls etc. from your insurer, it’s probably because a “flup” came due on a 30-day cycle of “keeping you engaged”, and constantly reminded where your money comes from.

 

 

 

Living With A Disability Claim – Lisa’s Addiction And Rehabilitation

(One of my long-time clients recently asked me to write her story in the hopes it would help others who became addicted with pain medications while on disability. “Lisa” is not my client’s real name. The message of this story, however, can be a lesson for those who continue to take prescribed pain medications.)

I came to know Lisa in the fall of 2011 when she phoned me to seek consulting services for a disability claim with Unum.  Since her employer allowed her to work at home, With stern conviction, Lisa explained to me that she suspected Unum was trying to deny her claim. Diagnosed with herniated disks, failed back surgeries and chronic pain, she described situations in which she felt Unum was managing her claim unfairly. I accepted her case.

Over the next several years many issues with Unum came to light and were resolved one by one, giving me the opportunity to speak with Lisa on many occasions. I began to notice that during our phone calls, Lisa’s tone and thought patterns began to change. She slurred her speech to the point that it was difficult to understand her, and it was obvious she was having difficulty putting simple sentences together. I remember asking her, “Lisa, did you just take your medication?”, to which she replied, “Yes, I just took it.”

Additionally, I believe that Lisa began to intentionally harm herself in order to present at the Emergency Room to obtain additional opiate medication. Although Lisa suffered additional injuries from a bicycle accident and a serious fall down her cellar steps, ER personnel were reluctant to provide her with medications in addition to what she was already taking.

Worried, I went back to Lisa’s medical records and found that in 2016 her pain management doctor prescribed the following medications:

• Fentanyl 100mcg patch
• Oxycodone 30 mg every 4 hours
• Oxycontin 40 mg every 12 hours
• Diazepam 10mg
• Cloridine 6 mg
• Amitriptyline 50 mg
• Ambien at bedtime
• Valium 10 mg 2 per day
• Adderall 2 per day
• Ibuprofen 800 mg every 6 hours
• Zoltran for nausea

By 2017 Lisa’s husband asked her for a divorce, and she moved to another state in order to make ends meet. As a devout Catholic Lisa mourned the loss of her marriage, middle class lifestyle, and home and added alcohol to the above mix of legally prescribed drugs. Concerned for my client’s well-being, I frequently emailed her ex-husband and expressed my concern with taking both Fentanyl and Oxycodone at the same time. Although  my concern was well received, I continued to worry that Lisa’s situation would not end well.

Lonely, and scraping to make ends meet, Lisa began a relationship with her former now married boyfriend. Her grown children deserted her, not willing to put up with her constant “highs” and irrational behavior. Unum continued to harass Lisa for more and more information adding to the stress of an already stressful situation.

Last year I received a call from Lisa’s “boyfriend” informing me that she was found unconscious in her living room and was taken to the Emergency Room – she was barely alive. Records reported that her liver and kidneys had already began to shut down. For days,  Lisa was listed as critical.

Fast forward to six weeks later I received a call from Lisa explaining that she entered into rehab for 4 weeks and had ceased taking all of the above medications. I marveled at the fact that Lisa actually sounded well, encouraged, and yes, happy. I congratulated Lisa for her recovery and told her how proud I was of her persistence to remain in rehab and get well. It was as if I were speaking to two different persons.

“Oh yes”, she said laughingly, “my boyfriend went back to his wife and guess what, Linda? I have a date tonight.”

“That’s wonderful, Lisa”, I said, “I’m so glad that you can now be happy and live your life drug and alcohol free.”

I am so proud of Lisa’s recovery and have every confidence that she will continue to live life the way she wants without the influence of drugs and alcohol.

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I have no doubt but that Lisa’s story is a success among many insureds and claimants who suddenly wake up one day and find themselves addicted to their opiate pain medications. Living with a chronic pain disability is very difficult and particularly stressful in light of the many additional external stressors that happen as part of real life in general, such as divorce and desertion by one’s children.

The combination of Fentanyl, Oxycodone, and Oxycontin are now viewed as “hot cocktails” that can be overdosed accidentially. We’ve seen the stories of celebrities, who after many years of bodily abuse, take prescribed pain medications in combination that resulted in their deaths.

In addition, there may also come a point when pain management physicians continue to prescribe medications, not for pain management, but to manage “addiction.” Adding alcohol to the mix of strong opiates is a risk no insured should take.

Lisa and I sincerely hope her story reminds insureds to continuously discuss opiate pain medication prescriptions with their physicians. Today, there seems to be a governmental focus on controlling opiates, and yet, physicians may still be prescribing dangerous levels of medications in combinations that could be lethal.

If you have any questions concerning your medications please make an appointment to discuss your prescriptions with your physician, or pain management provider, or go to the nearest Emergency Room and ask for help.

I continue to support disability rehabilitation efforts to treat medication addiction while receiving disability benefits.

 

 

 

 

 

 

 

Unum And “Reservation Of Rights” – Again?

Unum’ use of a pay status called “Reservation of Rights” is increasing once again and I’m seeing it more and more in communications. ROR can be a complex issue to define so let’s get started.

INTRODUCTION

All insurance companies are required to set aside funds sufficient to pay future claims. These funds, although unavailable to pay bills, do earn interest that further reduces Unum’s cost of claims. Increasing “financial reserves” adds to the company’s liabilities on its Balance Sheet, but decreasing reserves results in an immediate contribution to profit. Easily put – Claims IN = Liability, and Claims Denied = Profit.

There are usually several reserve figures recorded, one of which includes interest earned on the total financial reserve investment portfolio. Although Unum denied the existence of “claim reserves” on many occasions, we now know they do exist and are still used by managers to choose “the biggest bang for the buck” when targeting claims.

Unum’s BAS claim coding system allows entering Reservation of Rights status. This in turn reduces the financial reserve allowing the company to at least, in part, recognize profit on a claim that hasn’t been denied yet. Similar to the old “90 codes” used by Unum Life, the process of “assigning” ROR status to a claim that’s still paid ultimately results in a premature contribution to profit.

The process of “assigning” ROR status to legitimately solid claim liabilities forces claims handlers to scramble to deny claims when ROR is improperly recorded. The only entity that gains is, of course, Unum.

Unum’s management consistently responds that ROR status does not reduce financial reserves. If that were so, we would not see increases in the use of ROR status just prior to end-period profitabiity reporting. The public learned a long time ago to ignore what Unum SAYS and look toward WHAT IT DOES. Increasing the incidents of ROR status prior to profitability reporting is evidence that ROR status does have an effect on financial reserves.

PROFIT MANIPULATION

Unum always did find ways to manipulate Reservation of Rights by deliberately under-reserving, to unfairly assigning ROR to high value claims, and to demanding repayment of benefits paid. Manipulating financial reserves is a “hiding in plain sight” way of showing increased profit when in fact there isn’t any. If regulators and the SEC ever took an interest in investigating Unum’s actual reserves, a very different profit picture could potentially be uncovered.

While true liabilities remain, Unum engages in what is called “Off-Balance-Financing” by denying claims alleged to be questionable liabilities for the future. The real question is how does ROR status affect the insured and why is Unum stepping up its use, again.

ROR INSUREDS

When Unum places claims on ROR it sends out letters to insureds, stating the following:

“We are making a payment to  you while we complete our review. this payment and any possible future payments, until we tell y ou otherwise, are being made under Reservation o Right. Payments made under a Reservation of Rights cannot be interpreted as an acceptance of past, present or future liability for benefits. We retain all rights, including the right to seek return of any benefit that was not payable under the policy. we only pursue the return of such benefits in limited circumstances”

In the past Unum’s letters said, “…we only pursue the return of such benefits in case of fraud.”  Today Unum fails to specifically define “under what limited circumstances” it would demand repayment, I assume as part of the company’s new “nickel and dimming” of insureds by reducing benefits to recover.

Unum always goes through cycles of assigning more or less claims to ROR status. In general, increased volumes of ROR seems to happen just prior to month-end or quarterly profit periods. In addition, some Unum managers use ROR status more so than others to control profitability objectives for their own units.

Regardless of how you think about Unum’s deliberate motives behind ROR status, assigning it to claims is a clear way to use financial reserves as a process to manipulate profitability at the insured’s expense.

From the insured’s perspective, Unum’s correspondence usually scares people and they begin to put away benefits and not spend them. I don’t see this as necessary, but it is pretty scary.

What should be of concern, however, is that Unum is informing you they aren’t accepting liability for your future claims; and, it’s up to you to find out why and solve that problem.

Another problem for insureds is that once ROR status is coded, Unum managers are reluctant to remove the status. Remember, if ROR is removed from the BAS payment system, “the liability” is reinstated and financial reserves go back up. Some claims managers would rather deny claims unfairly than reinstate the liability (profitability negative). Again, insureds are deprived benefits because Unum’s objective is to manipulate profitability.

If anyone is interested, I have an article in much more detail on the subject of Reservation of Rights. Please send me an email letting me know you’d like to receive it.

Placing ROR status is Unum’s mantra to manipulate profitability and has been for quite some time!

 

 

 

 

 

Plan And Policy Interpretation – Pre-Existing Conditions

After speaking with several claimants this month it appears some are confused about pre-existing conditions and what ERISA Plans actually say about the matter. One claimant read the pre-x provisions and automatically assumed her husband’s insurer would conduct a pre-existing investigation.

The most frequent error is misinterpreting Plan language from the very beginning. All ERISA pre-x provisions (paraphrased) basically say that if an employee leaves work within 12  months of the Effective Date of Coverage of the Plan, there is a three-month look-back to determine if he/she received treatment, or took prescribed medications for the claimed disability. This is referred to as the 3/12 provision.

Keep in mind there are many versions of pre-x provisions written into various Plans; the above being the most common. The “mistake”, if you will, is in not using the EDOC or Effective Date of Coverage of the Plan to determine whether a pre-x investigation is necessary. To make things even more complicated, Plans often set conditions for when the EDOC actually is.

For example,  the EDOC might be “…for all full-time employees, the effective date of coverage, IS the date of hire.” Or, “…60 day waiting period for new employees.” Therefore, it is important to determine exactly WHEN the Effective Date of Coverage of the Plan was in calculating the 12 months before going out on disability.

To make matters even more complicated there are employers who change Plan insurers, adding “Continuity of Coverage” provisions in the new Plan. Therefore, for employees who were covered under the old Plan, the determination of pre-existing investigations is a bit different.

To explain, we can apply a series of questions. “Is the employee’s claim pre-existing under the new Plan? (And, it probably is.) Is the claim pre-existing  under the old Plan? (Probably not for former employees.) Therefore, no pre-existing investigation is necessary. New employees hired after the new Plan was obtained will, of course, need to wait the 12 months before filing a disability claim.

I think you can easily see how pre-existing provisions can be misinterpreted and misunderstood. A good example is the caller to DCS whose husband was hired by his company in 2014 when his Effective Date of Coverage was his date of hire. Today, with a date of disability in 2018, there is no chance his insurer will engage in a pre-existing investigation.

Claimants who can wait out the 12 months after the EDOC before filing a disability claim will not have to contend with a pre-existing investigation. Unfortunately, filing a claim earlier will not result in a payable claim since claims will be denied as pre-existing.

Insurance Questionnaires – “Wolves In Sheep’s Clothing”

All Insureds receiving private disability benefits have at one time received questionnaires from their insurers. Some are pretty straight forward in asking questions about the personal lives of insureds, others are multi-paged invasions of privacy that go far beyond the scope of claim investigation.

I recently had the opportunity of reviewing questionnaires from Reliance Standard, The Hartford and Unum. I observed that “Questionnaires” per se can be broken down into two major sections – legitimate update information and deceptive questions invading privacy.

While insurance companies do have the right to ask questions of an “update” nature they do NOT have the right to ask personal questions that are not work related or medically required in order to support claims. Insurers also have the right to SSDI financial information, and in the case of IDI policies, tax returns and certain other agreements. Beyond this, insurers ask questions when the answer should really be, “Mind your own business!”

Why does any insurer need to know the following:

• How many hours do you use your computer?
• How long do you nap? How many naps do you take?
• Do you do your laundry?
• Do you cook your own meals? Do you cook your family’s meals?
• How far can you walk?
• Do you go to Church?
• What are your hobbies?
• Do you garden?
• How many times do you go to the bathroom?
• Do you go out? Where do you go?

Some questionnaires go on and on asking personal questions about daily activities. At one time, (and I haven’t seen it for a while, thank goodness), Unum had a questionnaire asking insureds to write down all of their activities every 15  minutes. Healthy people would have a problem completing this kind of form!

Unfortunately, the first tendency of insureds is to fill up the page with as much information as they can – exactly the wrong thing to do. Somewhere along the line your sensibilities have to remind you that most of the questions are beyond the scope of claim investigation and that perhaps you don’t have to answer them. Remember, questionnaires are sent out in addition to the regular update forms, therefore, insurers are already informed of claim update information. So why the invasive questionnaires?

Insurers are well aware that insureds will do everything they can to “fill up the page” often attaching additional sheets. While the regular update forms are asking for genuine update information, questionnaires are deceptively asking about work capacity. Filling out an insurance questionnaire with writing in every space is exactly the type of information insurers use to allege you have work capacity and can return to work.

I’ve written several good blog articles about METs that you may recall. The Metabolic rate is expressed as an equivalent of the resting expenditure of energy for various physical activities. For example walking fast is 5 METs meaning the activity of walking is five times that of an average person sitting in terms of energy expended. Doing laundry is 8 METs, if downstairs in your basement, 11 METs.

Sedentary work capacity is equal to 5 METs, therefore, it doesn’ take very much activity to be able to return to work full-time in a sedentary capacity. Sometimes during cardiac rehab patients can perform up to 10-15 METs on a stress test. That’s “Light” work capacity!

Questionnaires deliberately ask questions about your daily activities in order to evaluate the total number of METs you are able to do in a day so that a conversion can be made to approximate METs performed, arriving at work capacity. An innocent mention of “I spend time with my kids” is equivalent to 10 METs and that is at least sedentary to light capacity for work.

Insurance questionnaires are always looking for self-admitted work capacity, and they do it in very deceptive ways. Insurers use fear and psychology to encourage insureds to “just fill up the page.” Frequently, insurers conduct surveillance shortly after receiving back questionnaires for the purpose of looking for “inconsistency of report.” For example, you say one thing, and surveillance observes something else. The more information you write on the questionnaire the tighter the hangman’s noose is.

“Yes” and “No” are still very good, truthful answers without all of the justification that insureds try to add in. Insureds always have the right to ask, “What does this have to do with the definition of disability in my policies?”

If you find your insurer with its nose in your business remember that everything you say on a questionnaire is converted to METs equivalent for physical work capacity. If you have difficulty filling out questionnaires, please feel free to give me a call.

 

Friday Q & A

Is Unum Long Term Care a good product?

Unum LTC was an unprofitable flop, and in fact, the company isn’t even selling it anymore. Class action lawsuits were filed against the company by CA policyholders of LTC who charged that they were denied maximum benefits due to “flawed calculations” using inflation factors. In 2016 policyholders were awarded $46M in a settlement as reimbursement for lost LTC benefits.

In retrospect, Unum seems to always be “calculating” something. It’s current initiative I’ve dubbed “nickel and dimming”  relating to SSDI recalculations involving Lucens may turn out to be yet another “miscalculation” that’s costing ERISA claimants benefits they can’t afford to payback if they don’t legitimately owe it.

In any event, Unum isn’t selling Long-Term Care products anymore and thank goodness for that!

Can your employer make you quit and go on disability?

No, employers don’t have to “make” you do anything, they can just terminate your employment. As you may know FMLA (Family Medical Leave Act) requires employers to keep your job open and continue to pay benefits for a period of 12 weeks. Beyond that, employers can terminate you with the blessing of the federal government.

Keep in mind employers may also terminate you for “poor performance”, but generally take the softer approach and recommend that you take advantage of the company’s STD/LTD programs. Employees who can’t perform on the job but who refuse to use STD/LTD can be terminated anytime.

Although employers seem to be sympathetic with employee health concerns the sentiment can quickly change if, and when, employees are unable to return to work after a period of STD. Therefore, employers really don’t need to force you to go out on disability, they can just fire you for poor performance if you don’t apply for disability and leave work on your own.

What do you think of Unum’s “Aspire” Program?

In my opinion, Unum’s “Aspire’ program of sending highly productive adult employees to Disneyland is demeaning and insulting. The selection process is flawed by choosing claims handlers who deny the most claims. I preferred “The President’s Award”, a much more prestigious honor for employees.

If you already work for Disneyland and the wicked witch, it’s not really a great prize to visit the same place and receive even more brainwashing. Frankly, I think the program should be viewed as insulting to grown adults.

Can I play golf while on disability?

Insureds keep writing to me and asking me this same question over and over again. Golf is a very strenuous sport that involves walking, bending, stooping, stamina, physical capacity, overhead reach, and concentration. The sport requires the use of arm, shoulder, and back muscles, legs and the ability to walk distances, weight bearing etc.

My answer is “NO!” Those with disability medical restrictions and limitations severe enough to preclude working shouldn’t be playing golf in my opinion.