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Recently, I discovered boxes of DCS, Inc.’s brochures and business cards that had not been distributed to interested insureds and claimants. If you wish to receive a DCS, Inc. brochure, please send a private email to: DCS@metrocast.net with your address and I will be happy to send you information in the mail free of charge.

If you would like more information about how to become a DCS, Inc. client, please feel free to give me a call at (207) 793-4593 and/or request the brochures I have available.

Thank you! I’m looking forward to hearing from you.

 

One of the most unfortunate consequences of having a private disability claim is the potential of insurance surveillance. Not only are insureds and claimants treated in the claims process as though they are deliberate malingerers for secondary gain, but privacy has also become an issue due largely to increased technology that makes surveillance profitable.

According to my own statistics related to claims, it is reasonable to say that nearly 50%+ of insureds and claimants will be surveilled this summer. Insurers are well aware of increased physical activity during the summer months and fully take advantage of naive insureds who mistakenly say, “Surveillance isn’t an issue because I don’t do anything wrong.”

Surveillance isn’t a question of “not doing anything wrong”, but rather recognizing the fact that once observed, functional capacity can be interpreted any way the insurance company wants to interpret it. You may “think” you aren’t doing anything wrong, but by the time your insurer interprets your observed activities, it will look like you have the functional capacity to return to work full-time.

And, of course, seeing is believing and the likelihood of a judge or jury having sympathy for someone they see on film riding a Jet Ski with a bad back is pretty slim.

Summer is a great time for insurers to take advantage of the most profitable risk management activity they have. DCS, Inc.’s position is that insureds should NEVER exceed medical restrictions and limitations, if only for the protection of their own health and well-being.

Be forwarned though….those insureds and claimants who risk having it both ways this summer may wind up with denied claims come Labor Day. Be smart, protect your health, and disability claim, and do not exceed your reported medical restrictions and limitations.

The insurance company’s drones will be watching.

 

If I were a Guardian/Berkshire insured I would be very concerned and vigilant concerning the company’s interpretation of its policy provisions.

In the last two years I’ve had the opportunity to review several claim situations where Guardian’s claims reps deliberately misrepresented policy provisions in order gain profit advantage at the insured’s expense.

Company reps appear to be engaging in claims practices that are out-of-contract leading me to believe reps are acting on behalf of management directives rather than reading actual contracts. At least one attorney reported to me that she had to petition the state department of insurance to intervene when Guardian refused to pay a claim because the attorney had her client sign a limited Authorization. The DOI agreed with the attorney, but it took nearly 6 months to clear up the issue.

It has also been reported to DCS, Inc. that Guardian’s reps are extremely hostile on the phone when actions are challenged, even to the point of hanging up on the insured. I have personally experienced the same hostility with Guardian which actually does not serve the company well. Insureds who are patient enough to deal at all with Guardian on the phone should opt instead for written communications only.

I know of at least two Guardian claims where the company insists on deducting prior business losses that “do not result from disability” from the PMI calculation. The Guardian scam is to conjure calculate a percentage of prior business losses and apply it to the Prior Monthly Income calculation (PMI) so that in carrying non-existent business losses forward insureds are penalized for future losses that do not exist.

I also previously reported Guardian’s “over-the-top” investigation schemes that exceed standards of investigation normally assumed to be necessary for disability claims investigations. Whatever it is that changed the company’s popular status in the disability insurance industry from 2nd behind Northwestern Mutual to a notable “bad faith” insurer is now obvious to most professionals looking to buy disability protection.

Unfortunately, I would not recommend Guardian’s disability policies to any professional given the company’s current erratic patterns of enforcing policy provisions to favor future business losses that do not exist.

The company is no longer reputable as a seller of disability protection because it no longer adjudicates claims in “good faith and fair dealing.”

Most disability claims submitted to US insurers are filed by insureds and claimants who do not have a clear or accurate understanding of their policies or Plans.

Although I receive many calls from people who are already “in trouble” with their claims, in most instances there is always a “weak link” that acts like a beacon signaling a claim denial is on its way.

Here is a list of the most common “weak links” contributing to disability claim denials all over the country. If you are managing your claim yourself and can identify at least two of the items below, your claim could be in jeopardy.

  • Lack of clarity, specificity and completeness of medical reporting.
  • Lack of distinction between “primary” and “secondary” diagnoses, or documentation of co-morbid impairments.
  • Treating physicians fail to support continuing form completion and become “not good at it” at time goes on, or tells you to find another doctor.
  • Primary diagnosis of any type of connective tissue disease such as Fibromyalgia, or infectious disease such as Lyme or Chronic Fatigue Syndrome that is not specifically managed in accordance with CDC criteria, or Plan language, or medically supported to counter insurer claims of “self-report.”
  • Insured or claimant continually bombards insurers with long-winded justifications and phone calls defending claim. OVER SPEAKING claim on a regular basis.
  • Using web portal email with insurance tracking software attached.
  • Constant dialog on social media, Facebook, Twitter, LinkedIn, etc. Opening the door to insurance scrutiny and access to personal electronic data. Failure to shut down social media.
  • Insured or claimant communicates by phone or web portal and provides information to insurers that can be used against them.
  • Insureds or claimants who are academically well credentialed who believe they “are in the know” and can manage their claims without specific knowledge or experience with insurance.
  • You have an attorney charging you exorbitant fees to “manage”, but isn’t really doing anything until the claim is denied.
  • Continuing to exceed medical restrictions and limitations and consider surveillance as inconsequential because, “I don’t do anything wrong.”
  • Frequent requests for field visits, and IMEs without proper insured management and preparation. Red flags are obvious, but ignored.
  • Surveillance reports defended with statements such as, “I have good days and bad days”, or “I suffered for a week afterward.”
  • Lack of continual supplementation of Administrative Record. (ERISA claims)
  • DI “own occupation” claims without specific percentage allegations in Job Description detailing material and substantial duties.
  • Insured or claimant is at the benchmark for having limited work capacity but physician fails to specify work and time limitations, or fails to document return to work is temporary as part of a work hardening program.

Although the above list of claim “weak links” is by no means all-inclusive, it does point out what may be brewing on the horizon for claim targeting and termination. Every disability claim has a weak link and it should be identified and addressed.

And by the way, I haven’t necessarily written this post to encourage business, but if you can identify any number of weak links to your claim then perhaps it’s time to hire a consultant with a really good set of pliers.

 

Recently, I was asked by an attorney to provide him with information from the “Linda Nee archive of Unum bad-faith files.” And, I was amazed to re-visit, and in some cases re-live” information that is clearly an indication of Unum’s mindset as a company – even today.

One of the documents I kept all these years was titled, “Indicators of Disability Insurance Fraud (Red Flags). Unum’s intro indicates that if two or more of the actions below are present, further investigation is required.

  • Recent increase in benefits (FIO) or indication of multiple coverage or over insured. (Ever wonder why Unum asks what other disability insurance you have?)
  • Failure to sign an Authorization or altering the Authorization. (“Suspending” benefits unless signed as is.)
  • An injury or illness coincides with a lay-off, plant closing, job termination, or down-turn of profitability.
  • Signature on attending physician’s statement is similar to claimant’s.
  • Claimant is active in sports or other strenuous activities. (Questions regarding “hobbies” are deliberate.)
  • Claimant frequently cancels medical appointments, or refuses to attend IMEs.
  • Disability stems from subjective complaints such as back pain, strain, headache, depression, or soft tissue injury. (FMS) (Who determines what is and isn’t “subjective?”)
  • Claimant is near retirement age, or in line for early retirement.
  • Disability extends beyond normal length of time.
  • Claim is submitted a short time after a contestable period has expired.
  • Claimant requests quick decision on claim or offers to negotiate benefits. (Readers should really think about this one!)
  • Claim forms submitted with demand letter by attorney enclosed. (Caution here!)
  • Insurance knowledgeable claimant submits all documents needed to process claim with initial proof of loss. (Avoid this “red flag” by having a consultant involved!)
  • Delay in submitting claim. Claimant alleges they forgot they had the policy.
  • Loss occurs at/or about the time of a financial crisis – Bankruptcy, loss of professional license, malpractice lawsuits, or failure of a business resulting in  job loss.
  • Claimant overly cooperative on the telephone, but less so later on. (Another great reason not to communicate on the phone!)
  • Claimant refuses current Authorization or limits use of Authorization to specific providers or treatment.
  • All documents photocopies, no originals. (This is less important with the changes in scanning and electronic transmission of documents.)
  • Claimant never at home when called, phones ringing in the background or commotion.
  • Frequent calls to examiner for status of claim. (Think very carefully about this one. I often receive calls from insureds who contact Unum way too much. Think!)
  • Subjective disability – soft tissue injury/depression or stress related condition. (These types of claims automatically create “red flags” and require special management.)
  • Unwitnessed injuries – especially if on private property.

The above identifiers come directly from Unum paperwork. There is no indication that the company changed its directives in the last 15 years.

My recommendation is to think very carefully about potential actions on your part that cause “red flags” and why the lion’s share of investigation winds up at your door, particularly if you are managing your claim yourself,

Keep in mind, there are probably many other Unum indicators involving social media and therefore the above list is not all-inclusive.

While assertive attorney involvement causes Unum “red flags”, a consultant well aware of Unum’s inappropriate assignment of “red flags” can keep insureds and claimants under the radar.

Apparently, there is a difference between “attorney demands”, and providing proactive claim assistance.

Does a Unum denial affect my SSDI?

I am not surprised at how often I’m asked this question. A disability claim denial does not affect SSDI approvals since the benefits are a federal entitlement that has nothing to do with private insurance.

SSDI approval is based on a 5-step procedure that determines whether an individual meets SSA “listings”, and has enough “quarters” accumulated to receive benefits.

Although I am aware that Unum in particular continues to attempt to obtain SSDI information it really has no right to, the bottom line is that Unum, a public corporation, has no authority when it comes to federal entitlements. Therefore, no private disability insurance denial has any effect on SSDI benefits.

How long do I have to submit ongoing “proof of claim” to Unum?

An easy answer to this question would be for me to say, “please read your policy or Plan” because deadlines ARE written into the documents. For Unum ERISA Plans, claimants are given either 30 or 45 days to provide requested information “at their own expense.”

The Plans also state in several places that “YOU” are accountable to provide the information. Unum’s objection to breaking the “chain of evidence”, so to speak, by insisting it obtain records directly from physicians is actually a request that is out of Plan or contract.

On occasion, Unum claims reps have strange ideas about enforcing short deadlines, but ERISA Plans allow 30-45 days as of the date the written request is received.

DI policies specifically state insureds have 90 days after the end of any month for which benefits are requested to submit proof of claim. Most insureds do not enforce these provisions because they want to get paid every month. However, Unum cannot deny a claim for “failure to provide” unless the request is over 90 days.

How does Unum calculate overpayments?

Although there are several previous posts on Lindanee’s Blog having to do with this question, the simple answer is that Unum’s program (which is the same one I helped to design when I was still there), calculates as follows:

What we [Unum] should have paid – What we did pay = overpayment – attorney fee = net overpayment.

Unum’s program actually breaks the calculations down into days, but in general, this is how all SSDI overpayments are calculated for nearly all overpayments.

How do I withdraw my Unum policy?

Simply write a letter to the claims handler after you receive your next benefit requesting that it be withdrawn. Although DCS, Inc. doesn’t recommend that claimants do this across the board, for some, it’s a good resolution.

Unum Group is the only insurance company I am aware of that cannot conduct it’s business  as usual during the summer and over holidays. DCS, Inc. receives many calls from worried insureds when checks suddenly do not arrive on time.

Unum claims specialists are permitted to take extensive PTO time during the summer months and around holidays. Although they are supposed to manually approve any benefits due before they leave, they usually don’t. This means insureds may have to wait until claims handlers return to receive monthly benefits due to them.

DCS, Inc. recommends that in this one instance, claimants should call Unum Customer Service and inform of late checks. I’ve heard that Customer Service Reps aren’t allowed to solve problems anymore so you just might hear, “Your claims rep is on vacation and you need to wait until she comes back.”

Although this is entirely inappropriate, Unum may release checks when it wants to. There is no consideration on Unum’s part for the fact that many insureds depend on their checks at the same time each month so that bills can be paid.

As I indicated, Unum Group is the only insurer that seems to have problems releasing benefit checks during the summer and around holidays. It doesn’t mean your claim is going to be denied, it just means your claim specialist is uncaring about getting your benefit to you when owed.