Daily Buzz – 12/17/2018

Lucens Gets Around

Sometimes it’s scary how much similarity there is between Unum Group and Sun Life. Unum lawyers and employees who quit camp usually pitch their tents at Sun Life Financial, the campground for Unum discontents.

As a result, many of the same unfair claims practices exist in both companies and similarities are a bit scary. Apparently, Lucens, Unum’s SSDI gopher, is also on board with Sun Life chasing the same information. Remember that disability policies do not contain provisions requiring claimants to disclose SSDI files and the same “No thank-you” should be given to Sun Life as for Unum.

I can only assume, like Unum, Sun Life is requesting SSDI information in order to calculate overpayments and nickel and dime claimants for everything they can get – an idea Sun Life probably grabbed from Unum management.

It’s OK to tell Sun Life that you prefer to keep your SSDI information private, and I highly recommend doing so.

Surveillance is in Full Swing

Several clients have notified me that they spotted the typical insurance peepers near their houses. Apparently, insurers are putting most of their eggs in the surveillance basket which is consistent with what I projected a month ago.

Please remember not to exceed your restrictions and limitations during this holiday season.

Approval Decisions Await 1/1/2019

In an effort to avoid a sudden uptake in financial reserves, insurance companies usually hold over approval decisions until after the first of year. Therefore, if you are waiting for a claims decision before year-end, you may be disappointed.

Denial decisions, however, are recorded right away to reduce financial reserves.

Insurance PTO Time and Late Checks

Most insurance employees take PTO time at this time of the year. This means there is little to no customer service available to you, and it’s likely you won’t be able to reach your claims handlers at different periods during the holiday season. Checks may be late particularly from Unum if claims handlers go out on vacation without approving benefits prior to leaving.

Although this may be the holiday season, most claims handlers won’t make the extra effort to authorize your checks. It is recommended that you call Customer Service as soon as you can if your checks are late.

Stay Off of Facebook and Social Media

All the insurance company needs is to see your face on a FB page explaining activities. DCS, Inc. clients already know to stay off social media, but it is highly recommended to readers as well. Facebook is no place to share your holiday cheer!

Another SSDI Advocate – Human ARC

Another SSDI advocate called Human ARC is out there offering advocacy for SSDI. This is in addition to GENEX, Allsup, and Advocator Group. DCS, Inc. does NOT recommend that any insured sign on with third-party advocates. The best course of action is to retain your own SSDI attorney from the beginning. Since fees are paid on contingency there is no out-of-pocket expense to you.

Even the name, “Human ARC” is a turn off, in my opinion.

Pre-Existing Conditions – Addendum

Recently, several insureds called to ask questions about pre-existing conditions. I’ve written several articles for Lindanee’s Blog on this issue and therefore I recommend that you Search from the Home Page if you are looking for specific, detailed information.

However, this is a good time to remind readers that pre-existing condition investigations should never happen. Most 3/12 pre-existing condition provisions require a 3 month look-back period when individuals file for disability within 12 months of the Plan’s Effective Date of Coverage. Therefore, barring an unexpected catastrophic event, such as a heart attack, it is preferable for employees to wait out the 12 months before filing for disability.

Most people who call me are asking if they can go out on disability as relatively new hires. It is NOT the intent of employers to pay for STD/LTD of new hires which is why there are pre-existing condition provisions in most Plans.

Pre-existing conditions are almost never litigated because the information is “objective” and not a matter of “opinion.” Either there are records of treatment or medication management for the claimed disability during the look-back period or there isn’t.

One of my callers described a situation where his wife mistakenly refilled an old prescribed medication in the three-month look-back period, and Unum denied his claim. As I said, pre-existing condition evaluation is objective and if the refill appears on the pharmaceutical record, the insurer can deny the claim.

One individual received STD, but was denied LTD because of a pre-existing condition. In this case, it would be preferable for the employee to return to work for the remaining three months (or, until he worked the full 12 months), and then go back out on disability. Notice, though, that he would have to return to work full-time with his same employer. Returning to work with a new employer negates the previous employer’s Plan, and he now has to meet a whole new 12 months from his date of hire in order to file for disability again.

In order to avoid most pre-existing investigations, employees should avoid filing disability claims until they have worked for the employer a full 12 months. Although there are many versions of pre-existing condition provisions the 3/12 is the most common.

Beware of Plans with “Waiting Periods” because the clock starts ticking after the Waiting Period is reached. For example, if John was hired on 1/8/2018 and his Plan has a 30 day “Waiting Period” before he is eligible for Disability coverage, then the Effective Date of Coverage is 2/8/2018, not his date of hire.

As I indicated earlier, although there are times employees cannot medically wait to go out on disability, it is likely claims could be denied if treatment or medication were taken within 12 months of the Effective Date of Coverage. Employees are much better off trying to “hang on” for 12 months before filing for disability.

 

Linda’s Christmas Message 2018

An elder woman in my town, known by everyone as the Newfield matriarch, once told me that our own success and happiness in this world is measured by our attitudes and perspectives toward the things that happen to us every day.

At the age of 85 Thelma had been through several cancer diagnoses, chemotherapy, double mastectomy, colon cancer, colostomy and DM II. Sitting on the porch with her one brisk autumn day, she grew solemnly quiet and said, “If they find more cancer, I’m just going to let it go.”

When I reminded, my elderly friend of how many times she helped me with her advice concerning attitudes and perspectives of life, she looked up at me with a cunning smile and said, “I just wanted to know if you were listening.”

Not too long ago Thelma passed away from a septic infection from her colostomy, and for quite some time I mourned the loss of her motherly wisdom directed toward people she knew and those who entered her path. Not once did I ever know Thelma to become discouraged, or angry at her situation or station in life, but rather I observed her courage, regardless of how physically restricted she might have been. She was always glad to see me, and we were very close friends to the last.

Thelma taught me a joy of life I wouldn’t otherwise have practiced in my own life, and I consider her influence a positive aid to me in assisting many disabled persons over the years.

Although we are finding ourselves living in difficult times, I will always remember my friend’s kind and loving lessons in accepting the realities of life with the dignity and knowledge of who we are.

I wish all of you the best of holidays. Please stay safe and enjoy your lives and families in the spirit of Christmas.

Linda

The Christmas Grinch – Surveillance Reminder

“And he puzzled and puzzled ’till his puzzler was sore. Then the Grinch thought of something he hadn’t before. What if Christmas, he thought, doesn’t come from a store. What if Christmas, perhaps, means a little bit more.”

Here we are within three weeks of end of the year profitability for the big Robber Barons. Lurking behind evergreen bushes, trees and hedges, surveillance investigators are out in full gear hoping to find evidences of “inconsistency of report” as many people push the envelope by exceeding reported medical restrictions and limitations.

It seems like the Grinch is waiting for insureds to do something wrong so the “who stole Christmas” becomes a giant corporation hoping to make profit in 2018 at your expense. This is just a friendly reminder that investigative teams are ready and waiting to gather information that can be interpreted as adverse to you.

This includes, by the way, Facebook, Twitter, My Space, LinkedIn pages that are susceptible to scrutiny by those looking to deny claims. Hacking into social media is now more the norm of surveillance rather than sitting in front of your house, hanging out the window with a video recorder.

Please be aware of the possibility of Grinch surveillance and act accordingly.

Friday Q & A

Does Unum ever accept “verbal” Authorizations?

No, no, and hell no. An Authorization from an insurance company must be in writing. In an industry where “he said, she said” runs rampant, can you imagine the abuse that could happen with verbal Authorizations?

The purpose of any Authorization is to give insurance companies permission to request medical, occupational or financial information as part of their claim investigative process. You can’t give a “verbal authorization” to someone else. “Verbal Authorizations” will ultimately get insureds into more trouble than written ones ever will.

Does Unum engage in workplace harassment; and, what is the Unum Intranet?

Well, I’ve written quite a few blogs about how Unum treats its employees and lets just say, “it ain’t good.” Anyone who works for Unum knows “it’s their way or the highway”, particularly in the last several years with frequent firings of entire departments. I’m going to defer you to my other posts for specifics, but Unum employees should remember that keeping a journal of activities on the floor, team meetings, 1/1s with managers etc. is an absolute necessity for your own protection. I’m answering this question because I know Unum employees read this blog, and probably are the ones asking questions. I’ve left my door open to any Unum employee who may want to contact me with information, or to share their experiences as an employee. I’ve been there, believe me.

The Unum Intranet is an internal, company wide, computer communication system “FOR EMPLOYEE EYES ONLY”. In fact, attorneys should be including downloads of Intranet information as part of their disclosure demands. Information that is not included in Unum’s Benefit Manuals are communicated to employees through the Intranet. At one time there was a write-up about me on the Intranet; it may be still there! Everything inside Unum is covert and secret, or so management thinks!

What’s with Unum’s Reservation of Rights? It’s not in the policy!

You’re absolutely correct, ROR isn’t in the policy contract, but is used as an assigned “pay status.” Claims specialists have the ability on BAS (Benefit Administration System) to code ROR status. I believe BAS still integrates ROR with the claim financial reserve by reducing it and producing profit. Unum officials absolutely deny this integration, but it’s very persuasive when incidences of ROR are more frequent just prior to profitability reporting periods.

ROR assignment to claims doesn’t affect (add or subtract) to benefits, but it does have the capability of producing “off-Balance Sheet” reduction of liabilities leading to profit reporting. This is how Unum can get away with ROR even though there is no mention of it in the actual Plans or contracts.

By the way, other insurance companies do not usually put claims on Reservation of Rights status probably because they prefer not manipulate their financial reserves the way Unum does. For details about Unum’s financial reserves or ROR status, use the Search box from the home page.

 

Understanding Terms

A Few Industry Terms

Activities of Daily Living

Typical activities of daily living include: toileting, bathing, ability to prepare food, transferring (from bed to walking etc.), and dressing oneself. Physician documented ADLs of 2 or most usually qualify individuals for Long-Term Care benefits.

Disability Insurance

Disability insurance is intended to replace wages, salary or income during periods of medical impairment which prevent you from performing the important duties of your occupation or job. It should not be regarded as retirement income, unemployment insurance, or worker’s compensation.

Effective Date of Coverage

If your date of disability occurs before the date you are covered under your group LTD plan, you are not covered, and therefore would not be eligible for benefits. Most EDOCs are the same as the employee’s date of hire.

Elimination Period

This is a period of time for which benefits are NOT paid beginning with your Date of Disability and ending the day after the last day of the elimination period. All group Long-Term LTD policies have Elimination Periods in an attempt to eliminate relatively short-term illness from collecting long-term benefits. Some group STD plans have “no EP” which means you can begin collecting right away.

Many people get confused in differentiating between a WAITING PERIOD and an ELIMINATION PERIOD. Remember, a WAITING PERIODis how long you have to wait to sign up with your employer for LTD insurance, and an ELIMINATION PERIODis how long you have to wait in order to receive benefits once you file a claim. This is the easiest way to understand the difference.

Group Long-Term Disability (LTD) Insurance

Most group LTD policies are provided to employees by the employer who may pay all, part, or most of the premium. The employer is considered to be the “policyholder” and the employee is the “certificate holder.” Each employee receives a “certificate booklet” describing the provisions of their LTD policy. Group polices are regulated by the Employment Retirement Income Security Act of 1974. There are some group policies not regulated by ERISA, but these are in the minority. ERISA Plans are not individually underwritten and the risk is spread out among all members of the insured employer group.

Indexed Pre-Disability Earnings

When your Plan or policy mentions “indexing” it is the contract’s way of taking inflation into account, but only when other calculations are required, such as in the determination of how much you are to be paid if you are working. “Indexing” is NOT the same as a Cost of Living Allowance and shouldn’t be confused with “indexing”. You need to make sure you take notice of “where” in the contract indexing is mentioned and in what context. Indexing is NOT a COLA and care should be taken not to confuse the two.

Individual Disability Income Policies

IDI policies are purchased from an agent and are individually underwritten by the disability insurer.  The insurance company assumes all of the risk of any future claims. These polices are not regulated by ERISA. IDI policies are income replacement policies and insureds must prove they were working just prior to submitting disability claims.

Member of an Eligible Group

In order to be covered by your employer’s group LTD plan you must be IN an eligible group. For example, your policy may say the following: “All full-time employees and salespeople in active employment.” If you are working part-time, you would not be covered. Or, it may say, “All full-time employees with annual basic earning of more than $50,000.” Obviously, if you are a secretary earning $20,000 per year, likewise, you are not covered.

Minimum Hours Requirement

The numbers of hours an employee must be working in order to be eligible to receive benefits. Example: “Employees must be working at least 30 hours per week.” If you go out on claim, and never return to work, you are not eligible to receive benefits on a second claim since you were not working the required number of hours.

Non-Integrated Policy

A policy which does not allow benefits to be reduced by other income such as SSDI, pensions or worker’s comp. No offsets!

Pre-existing Condition

A pre-existing condition provision defines, “a condition for which you received medical treatment, medical advice, care or services including diagnostic measures, or taken prescribed drugs for medicines for your condition during the given period of time as stated in the plan.” The most common of these is the 3/12 pre-existing period condition.

Basically, if you file a disability claim prior to having worked for your employer for 12 months beginning with the Effective Date of Coverage of your policy, there is a 3 month “look back period” to determine whether a pre-existing condition exists. If there is, no benefits will be paid.

Recurrent Provision

If you attempt to return to work full-time and you are unable to continue within 6 months of doing so, you may go back out on claim without having to meet another elimination period. This information is not often communicated, but it is important if you just can’t work after you thought you could. The problem is that the insurance company will put you through another investigation from hell before putting you back on claim.

Self-Reported Symptoms

These are manifestations of your condition which you tell your doctor that are not verifiable using tests, procedures or clinical examinations standardly accepted in the practice of medicine. Example of self –reported symptoms include, but are not limited to headaches, pain, fatigue, stiffness, soreness, ringing in ears, dizziness, numbness and loss of energy. The following impairments are often claimed to be self-reported: Fibromyalgia, Chronic Fatigue, Lupus, Multiple Sclerosis, CRPS, Lyme disease, Migraine Headaches, Tinnitus, Cognitive Dysfunction, and Depression.

Waiting Period

A waiting period is that period of time an employee must wait in order to be eligible to participate in an employer’s group LTD plan. Some policy provisions say: “None”. This means you are eligible to participate in the group plan as of your date of hire. Others require you to wait 30, 60, 90 days, sometimes up to a year before you may sign up to participate in the plan. Generally, you have 31 days to sign up for group LTD insurance once you become eligible. If you miss this deadline, you have to file what is called “Evidence of Insurability”which means your coverage must be underwritten outside of the covered group.

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Insurance Slang…..

“…cut me off”   Is this what you really mean to say? Do you mean instead “…terminate (or deny) my benefits? The expression, “Cut me off” has really become part of a universal slang that is now being used by many claimants.

“…hit my bank”  Do you really mean to say “…my electronic deposit wasn’t made yet?” “Hit my bank” is also considered insurance slang and almost sounds like robbery rather than referring to benefit deposits.

…”they are going to deny me.”  Actually, insurers deny your claim, not you. Do you really mean to say, “…they are going to deny my claim?” It’s so easy to personalize a disability claim, but the word “claim” refers to a thing, not a person.

“…I have fibro (or brain) fog, or chemo brain.”  These two expressions are still widely used even though they are regarded as stereotypical jargon, and in some circles, nonsense. When used on forms to document disability, the expressions really do not describe much and aren’t helpful. A better statement for an FMS patient might be, “I have difficulty with expressing my thoughts, verbalizing words, and remembering things.” What is “chemo brain” anyway? Do you really mean, “Since going through chemotherapy I have residual side-effects that affect my memory and ability to relate and react in reasonable ways?”

In my opinion both of the “fog and brain” expressions dishonor the disability they are intended to describe, even though I hear and see treating physicians still using the terms.

 

 

 

 

 

 

 

 

 

 

 

CIGNA Disbelieves Its Own IME

In 2015 CIGNA was slapped with a Multi-State Settlement Agreement very similar to that of Unum Life Insurance. The CIGNA investigation resulted in discovery indicating the company engages in unfair claims tactics, and it was fined.

Here we are three years later, and the company is still engaging in unfair tactics to deny payable claims. Case in point is CIGNA’s denial of a Life Waiver of Premium based on its own IME wherein the examining physician said the insured was unable to work. From the IME report CIGNA alleges it was able to abstract restrictions and limitations that lead to the finding of alternative occupations, and the Life Waiver was denied.

Next step is to deny the disability claim at the change in definition. Without allowing the insured’s physician to write a rebuttal, CIGNA denied the claim most assuredly to recapture a $2M financial reserve prior to year-end. It’s mind-boggling!

I also begin to wonder about the CIGNA people, who by the way, are so paranoid they don’t include their last names to identify themselves on letters. Claims handlers know exactly what’s going on, but usually choose to hurt people in order to protect their jobs.

Because of the very large monthly benefit, this case may very well wind up in court. In my book CIGNA remains one of the “bottom feeders” in the disability world of unfair insurance companies. Disbelieving its own IME is a new low even for CIGNA.