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Lincoln Financial is by far one of the most deceptive private disability insurers there is. I hear a great deal from employers who, frustrated and fed up with Lincoln’s deceptive practices, eventually move on to other Group Plan insurers.

Although most insurers today engage in the same old unfair claims practices, Lincoln seems to go out of its way to be deceptive. Seemingly kind and well-spoken managers assure claimants all is well until a denial letter arrives suddenly in the mail.

“But, that’s not what you told me!”, one claimant informed DCS, “Lincoln assured me I would be able to submit additional information, but then denied my claim. Why?”

Lincoln’s representatives and managers are not truthful. The claim was suddenly denied in order to meet profitability targets for 1st Qtr. Despite all else that was told to the claimant and her manager, (she was working part-time), Lincoln denied the claim without updating medical information. Now, the claimant is forced to retain counsel for an appeal that will further reduce her benefit and money she has to live on.

I wonder sometimes whether my readers take me seriously when I caution them that insurers deny claims in a timely fashion for profitability. If insurers can reduce financial reserves, reserve “gains” are realized and there is an immediate contribution to profit. Placing claims on Reservation of Rights status is the same as engaging in “off-Balance Sheet financing” by significantly reducing future liability for claims.

In my opinion, most private insurers are significantly “under-reserved” meaning there’s not enough actual cash placed in “reserve” to pay future claims. I think if regulators took a closer look at companies such as Lincoln, and Unum in particular, they would find that these companies are under-reserved and lack cash resources to pay future claims.

Nevertheless, it is unfair and deceptive for Lincoln to inform claimants they can submit additional information and then before they can do that, deny claims. Lincoln Financial also has a deceptive appeal review procedure that denies claimants the full 180 days allowed for ERISA appeals.

Further, I doubt very seriously Lincoln actually puts any weight at all on medical documentation sent in on appeal. In most cases, Lincoln only takes about a week or two to review the information and then affirms that the previous denial decision was correct. The company also refuses to review any additional information sent in within any remaining days left on the 180-day ERISA timeline stating, “you’ve exhausted your Administrative appeal.”

In my opinion, no employer should buy Lincoln’s group Plans without a specified service agreement. I think that employers may not know that they can ask for “service agreements” demanding certain levels of customer service and payment of claims. If Lincoln doesn’t measure up, annual premium paid by employers can be reduced.

Currently, employers are running to the hills when they discover Lincoln’s deceptive manner of doing business. In any event, those who have claims with Lincoln should make every attempt to “see and listen through” the company’s baloney.

Lincoln doesn’t deal honestly particularly when a profitability period is right around the corner. This kind of deception is an unfair claims practice.

Every time I begin to think I’ve heard it all from Unum, I have an opportunity to review another claim that opens a new door to egregious conduct.

Although I’ve posted many times that “Unum knows nothing about actual physical or mental disability”, that message was made undeniably clear when the company denied a claim for a physician diagnosed with breast cancer.

The United States has many good sources of information for women diagnosed with breast cancer, the three most common being the American Society of Clinical Oncologists (ASCO) Guidelines, the American Cancer Society and the National Comprehensive Cancer Network.

These organizations, among others, publish established guidelines and recommendations for women who have had mastectomy and are survivors of breast cancer.

The ASCO, for example, states:

“A majority of patients will experience some level of fatigue during their course of treatment; however, approximately 30% of patients will endure persistent fatigue for a number of years after treatment. Fatigue is one of the most prevalent and distressing long-term effects of cancer treatment, significantly affecting patients’ quality of life.”

The ASCO/ASC also publishes guidelines that recommends against taking aromatise inhibitor medications for joint pain because they have been proven to be ineffective. Finally, the ASCO/ASC also recommends to physicians, “Actively encourage all patients to engage in a moderate level of physical activity after cancer treatment such as fast walking cycling, or swimming and strength-training.”

Unum recently denied a claim for a physician, let’s call her Mary, diagnosed with breast cancer who underwent bilateral mastectomy, chemotherapy and radiation. Fighting residual side-effects, infections and reconstruction surgery, the physician repeatedly returned to work part-time, and on occasion full-time.

Mary was able to return to work because, as she stated, “I adhered to the guidelines of the ASCO, SSC, and NCCN that made recommendations for me to remain as active as possible, exercise, and avoid medications known to have no effect on my pain.”

While Unum initially approved Mary’s claim back to the original mastectomy, it later denied the claim alleging she could return to work full-time without restrictions. Unum’s reason for denying the claim were two internal write-ups stating that because Mary was exercising and not taking any pain medications, she could return to her own occupation full-time. Mary promptly retained counsel given that her monthly benefit was in excess of $10,000 per month.

Clearly, it’s unfortunate that Unum chooses not to support the recommendations provided to breast cancer survivors who follow guidelines in order to maintain optimum health following surgery and treatment. Mary attempted to return to work 6 times and was unsuccessful due to fatigue issues in addition to complications from reconstruction surgery.

Still, Unum completely ignored the recommended guidelines published by the above cancer organizations and denied Mary’s claim anyway. While it seems reasonable to expect Unum, as a disability insurer, to support women’s issues, it is not comforting to know that the company’s profit motives to deny legitimate claims takes precedence regardless of published guidelines by medical organizations such as those described above.

In thinking about this issue, it is also obvious to me that Unum also does not support organizational guidelines associated with Fibromyalgia, Chronic Fatigue, or HIV/AIDS either. Breast and uterine cancer and FMS are women’s issues and Unum’s internal “all male” medical staff do not appear to support issues related to women.

Further, Unum’s irresponsible attitudes toward recommended medical guidelines as well as its refusal to support feminist impairments forces women to make critical decisions between generally accepted medical treatment and continuing to receive benefits under the terms of their private disability policies.

In my opinion, one can conclude here that the only rationale used by Unum’s medical department to pay or not pay claims are internal medical reviews conducted by physicians who are paid annual bonuses to agree with Unum’s agenda to deny more claims.

Cancer organizations recognized as medically credible are ignored by Unum who apparently places profitability ahead of recuperation, healthy living and quality of life. One has to often wonder where Unum’s internal physicians hail from when their denials allege women can return to work full-time as cancer survivors.

I may be all wet, but it occurs to me that disability insurers have a responsibility to support women’s issues and medically agree with standard recommendations concerning treatment and post-surgical recuperation including the issues of overwhelming fatigue. It would also help if Unum would abide by the treatment plans recommended by treating oncologists who recognize the struggles women have as cancer survivors.

Notably, Unum’s internal physicians who evaluate women’s cancer claims are exclusively men.

Surely Unum isn’t going to get a great deal of public support by ignoring women’s issues, particularly those that relate to breast cancer. If ever you thought Unum’s claims practices were unfair and egregious, read no further.

I am constantly appalled at Unum’s total deliberate ignorance of women’s issues related to breast cancer survivors.

Ignoring public organizations who actually recognize and deal with women’s issues related to breast cancer is a mistake Unum may come to regret in the future.


DCS is a national consulting organization that provides expert claims management services to those with private insurance. I offer free initial consultation.

If you are interested in becoming a DCS client, please feel free to visit my website at: http://www.disabilityclaimssolutions.com

  • Telephone: (207) 793-4593
  • Fax: (207) 274-2331

Detailed information about DCS, Inc. can also be viewed on this blog by clicking the “Consulting Services” Tab from the Lindanee’s Blog Home Page.

Recent claims brought to my attention point directly to Unum’s medical review procedures that are still in violation of the intent of the Multi-State Settlement agreements and related amendments. Unum still completely ignores the recommendations of treating physicians and simply states, “…our board certified physicians disagree.”

The files I reviewed are IDI non-ERISA claims and have nothing to do with “discretionary authority.” Unum seems to be of the opinion that it can ignore all information obtained, either patient notes, or through doc-to-doc calls and make decisions based solely on its own medical opinions. I don’t think it would be outlandish to call this insurance procedure a scam.

Unum’s claims practices are totally unconscionable. How easy is it to deny private disability claims when the only medical opinions considered are its own biased, profit motivated medical write-ups?

Let’s  understand this process. Unum sells policies, collects premium, and then based on what is generally called a “conflict of interest” Unum decides not to pay. It’s outlandish! In addition to a profitably motivated self-interest, Unum actually pays its internal medical reviewers an incentive bonus to support the company’s denial agenda.

Reliable inside information reveals that those physicians who have the best claim denial numbers receive the highest percentage bonuses. Unum threatens its physicians with immediate termination if they share how much bonus they received. March is bonus month at Unum and its internal physicians can be comforted by the thought that parking their ethics at the door can be profitable.

Unum’s denials of legitimate claims for profit are unconscionable. Suspending benefits without reinstatement of rights of appeal are unconscionable! Despite the fact that Unum could be fined an additional $145M for demonstrating continued unfair “patterns of business practice”, regulators remain blind to Unum’s internal medical review processes and let the company operate unregulated.

This is something that should not be happening in America anymore – the complete deception of the insurance industry that is allowed to continue selling policies for which they have no intention of paying on.

Insureds need to be aware that Unum’s medical review is unfair and biased. Although this is something that could be fixed with a petition to Maine as a lead regulator, it won’t happen because insureds want to remain anonymous.

Still, it’s happening folks, and anyone who buys a Unum policy should be aware of the unfair medical review process that essentially is a Unum scam.

Friday Q & A

What’s going on at Unum? My claims handler seems like she’s out to lunch?

I’ve noticed myself in the last year or so that Unum Group’s claims handlers are indeed out to lunch. It isn’t just that the company can’t seem to find paperwork, but also the claims handlers are NOT reading the files and are making huge mistakes.

This means that the complex process of filing and managing claims is made even more complicated when insurers can’t get their acts together administratively. Recently, I asked a Unum client rep to forward an IME report to a treating physician for independent comment. Unum responded that we were not entitled to a copy of the claim file when we never asked for that. The rep’s title was, “Associate Benefit Specialist” meaning she was still a “U-numbie” and should have been supervised.

It appears to me that Unum is going through another “transition” of some kind and is extremely inefficient and let’s say, (to be nice), un-knowledgeable. It’s a nightmare dealing with claims reps who have absolutely no idea what they are doing.

Unum’s IT department is going to India, and that will probably make things even worse.

What day does Unum release checks?

At least in theory, Unum releases checks 5 days prior to the beginning of insureds’ or claimants’ “benefit payment periods. Therefore, every insured or claimant has a different  pay period. The benefit payment period begins on the day after the end of the Elimination Period and forward.

For example if your 90-day EP ended on March 10, 2017, your first benefit payment period would be  March 11, 2017 – April 10, 2017 and so on. Next would be April 11, 2017 – May 10, 2017.

Unum doesn’t release checks all on the same day as other insurers may do.

I didn’t pay Unum back my SSDI overpayment lump-sum. Can Unum take my tax refund?

If you signed Unum’s revised Payment Option Form giving the company a voluntary lien on all your assets, Unum may be able to obtain a court order placing a lien on your tax refund and any other money or cash assets you own.

DCS does not support not paying back SSDI overpayments when you’ve promised to return any amounts Unum fronted while waiting for SSDI approvals. Both parties need to play fair in the disability claims process. If you opted for unreduced benefits, then you need to pay insurers back when the SSDI overpayment is received. If you don’t want to pay back any money then you need to choose “Option A” and allow Unum to deduct an estimate from your benefit.

How do I handle an initial phone call from a Prudential claims rep?

As part of your application you request that all future communications be received in writing only so that you can accumulate a full written record of all your dealings with Prudential.

No insured is obligated by Plan or policy to provide information verbally. Request all communications in writing so that you actually have an opportunity “to think” about the answers before forwarding to any insurance company.

Insureds taking opioids or other pain and/or depressant medications should not be speaking with any insurance company on the phone.

Can Allsup or GENEX go into my checking account and automatically take the overpayment without telling me?

Please read the Authorizations you sign. To my knowledge both of these companies include in their Authorizations a paragraph that allows them to do this. If you don’t want Allsup or GENEX to have access to your bank accounts line out the appropriate sentences on the Authorization and do not give out any bank information.

One mistake in transfer could wipe out all of the funds in your account and it would take forever to get it reimbursed. I do not recommend giving anyone access to bank accounts except for electronic deposits.

 

http://www.newyorkpersonalinjuryattorneyblog.com/2008/02/state-farm-hit-with-civil-rico-claim-over-sham-medical-exams.html/amp

Although State Farm is the company mentioned in the article, all insurance companies basically operate the same way.

ADDENDUM

Word from a reliable legal source, “That case, and two related cases, was dismissed in favor of the defendants. It would help an insurer like Unum argue that those outside peer review/IME companies are not fraudulently conspiring with Unum.

Thank you, for letting us know the final disposition of these cases!

One of Judy Judy’s most famous sayings is, ” Don’t pee on my leg and tell me it’s raining.” When I think about this old saying, no doubt from an elderly grandmother somewhere, I can’t help but think about private disability and how often claims reps are forced to “keep the game going” when they know claims are about to be terminated.

Insurance company reps deliberately keep their thumbs in the dike   to keep everyone calm just prior to the breaking of the dam.

Most claims review processes require validation, or approval, from claims managers who spend time manipulating claim reserves in the company’s favor. But, in addition to that, “claims review” per se is viewed internally as a series of covert actions, kept cautiously secret from anyone outside the organization – particularly the insured.

This is one of the reasons why DCS doesn’t recommend speaking with claims reps on the phone. Claims employees are company trained to selectively document only what is favorable to them, ignoring all other communications favorable to insureds. As the first rung of contact with insureds and claimants, representatives are expected to “keep the peace” even if they have to lie about what the status of the claim really is.

Claims handlers are, for the most part, glorified administrative assistants. They refer claims back and forth to various internal resources for review, but have no autonomy to make claims decisions on their own. Insurance reps are also required to sign letters they don’t write, which is one thing I always thought was insulting when I worked for Unum Life Insurance so many years ago.

Insureds could be talking with any insurance claims rep on the phone listening to, “there is nothing wrong with your claim” while at the same time the rep knows the claim was recently referred to his/her manager for validation of a denial.

While claims reps are “putting you on” during initial phone interviews, he/she also knows your claim is scheduled for roundtable triage where it is likely the claim will be approved for denial. Unum claims reps, for example, fail to tell you when medical records have been requested without your knowledge, or when doc-to-doc calls have been arranged.

In my opinion, the most egregious deception is when insureds speak with reps who know that surveillance is currently taking place, or that the claim was referred for surveillance, and communicates as though nothing is happening. There is something so wrong with that picture. It’s all so 007-ish, but at the end of the day, insureds and claimants are kept in the dark, deliberately, about the status of their claims.

The obvious elephant in the room here is that all insureds and claimants are presumed by insurers to be filing fraudulent claims until proven innocent. Therefore, the claims process is shrouded with mystery, and underhanded strategies designed to trick and deceive insureds into “giving up the truth” of their deceptions.

In truth, according to Unum’s own statistics nearly a decade ago, there were only 10-15 percent of insureds who file fraudulent claims. Those figures have probably increased to up to 20%, but the entire claims process appears to be wrapped around finding that 20% of insureds who file claims for secondary gain.

The Hartford, for example, now assigns three people to each claim, one of which is a private investigator. I’ve spoken to several Hartford investigators and there is a paranoia about their perceptions of dishonesty in the private disability insurance industry.

Over the last 25 years I’ve probably spoken to a hundred people who told me, “I’m sure my insurance company is honest”, or, “They wouldn’t tell me something that wasn’t true would they?”, and finally, “How can they do that?”

In fact, I’ve discovered that insurers have made misrepresentation and deception so common place that Kevin Costner in the movie JFK said it all, “black is white and white is black.”

Those of you who are still communicating with disability insurers on the phone are risking their claims due largely to “double-talk” that’s probably not true at all. As a general rule, claims reps won’t be as deceptive in writing as they are on the phone.

Insureds and claimants, as Judge Judy infers, should always know when the insurance company is peeing on their legs, but says it’s only raining.

Truth is, you won’t ever know what’s going on internally with your claim, and there’s no one there who will tell you the truth.

Most claimants with employer-provided ERISA Plans are unaware of the “change in definition” after 24 months until their claims are denied. This is very unfortunate, since the change from “own occupation” to “any occupation” can be managed successfully.

Basically, most ERISA Plans pay benefits if claimants are unable to perform their “own occupation” for the first 24 months. Notice that the definition says “occupation” and not “job.”

Occupations are most often further defined as “occupations as they are performed in the national economy”; therefore claimants, often miss the all important fact that ERISA Plans do not insure their jobs, but only occupational definitions as maintained in a 1970’s outdated Dictionary of Occupational Titles.

After 24 months, most ERISA Plans change the definition of disability to say that claimants are only disabled if they cannot perform ANY occupation in the national economy (on a full-time basis). This definition of disability requires a much more difficult burden of proof quite similar to that of the Social Security Administration for SSDI.

Unum’s “any occupation” review process literally floats from not paying attention to the any occupation change, to aggressive focus on it, to managing it at any point in the claims history, even after 10-15 years of paid benefits.

Let’s face it, a change of definition after 24 months ( 12, 36 or 60 months is also possible) is written into most ERISA Plans and any insurance company has the right to create a process that eliminates claims at this point.

Unfortunately, insurers are not good at actually managing “Transferable Skills Analyses” (TSAs). The process works by the GIGO principle, or Garbage-in/Garbage-out meaning that if the claims handler doesn’t update all claim information prior to the TSA,  misrepresented conclusions will determine the outcome.

Transferable Skills Analysis involves calculating what is “gainful income”, and potentially indexing. Very rarely do I find either one of these two items documented in the Administrative Record. Far too often updated information is not used in the process and very old restrictions and limitations have worsened over time. Most of the time far too many insurance companies are in too much of a hurry.

In preparation for 1st Q 2017 profitability results someone at Unum punched the “aggressive” button and several claims I know of have been denied. I was made aware of this because several claimants called DCS to obtain information about “next steps” and referrals to good ERISA attorneys.

One claimant told me, “I sent in an appeal letter, but Unum refused to pay my claim.” Ouch. Once the ERISA Administrative Appeal is over the only option left for the ERISA folks is to try to interest a good attorney in their case to the tune of 30% back and up to 40% of future benefits to maximum duration, assuming litigation is successful. Double ouch!

To begin, claimants cannot overturn a denial on appeal with a letter. In particular, from what I’m hearing from lawyers I work with, Unum doesn’t overturn denials without a fight. Lincoln Financial doesn’t either and, in my opinion, deprives most claimants attempting the appeal process on their own of most of their ERISA appeal rights.

In at least some instances, any occupation denials shouldn’t happen. There are ways of supporting claims after 24 months that adds information to the record supporting permanent total disability.

DCS, for example, provides claimants with a reasonable plan of action, using Plan definitions and medical evidence to support disability beyond 24 months. I’ve been providing this kind of assistance for over 16 years, and although there are never any guarantees of success, DCS clients have access to information about the process and what needs to be done to manage it.

In any event, Unum is once again in its aggressive mode concerning conducting TSAs, and, in at least one instance denied a caller’s claim after paying benefits for 10 years!

It is very unfortunate that claimants are kept in the dark concerning this aspect of their ERISA Plans until it is too late. Consider.

Any occupation investigations are literally the last opportunity for ERISA insurers to deny claims, and lots of them. How much time and resources do you think YOUR insurer will put into the investigation?

This process also deserves as much time, energy and expertise from claimants in order to make the best possible defense for keeping benefits beyond 24 months.


DCS, Inc.  is a fee based, national consulting organization that provides expert claims management services to those with private insurance. I offer free initial consultation.

If you are interested in becoming a DCS client, please feel free to visit my website at: http://www.disabilityclaimssolutions.com

  • Telephone: (207) 793-4593
  • Fax: (207) 274-2331

Detailed information about DCS, Inc. can also be viewed on this blog by clicking the “Consulting Services” Tab from the Lindanee’s Blog Home Page.

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