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Friday Q & A

Where are Unum checks mailed from?

Unum’s checks are mailed from Columbia, SC. All communications into and outgoing from the company also come from Unum’s data center located in Columbia, SC. I understand Unum is in the midst of a chaotic reorganization right now, but so far it looks as though the checks will still come from SC.

What is a Life Waiver of Premium claim?

Most disability policies (and life policies) have a Waiver of Life Premium provision that excludes the payment of premium for life insurance while on disability. Policies also exclude the payment of disability premium while on claim.

Life Waiver of Premium provisions most often require insureds to be totally disabled from performing ANY occupation and therefore it is possible to get paid for an own occupation disability claim, but the Life Waiver is denied.

For example, during the first 24 months of a paid claim, the insurer pays for own occupation disability but doesn’t accept the insured is totally disabled from ANY occupation. Therefore, it’s likely that Life Waiver of Premium won’t be approved until the transferable skills analysis is done at the any occupation to determine if the insured is totally disabled from ANY occupation in the national economy.

Please do not get confused with “disability premium waiver” and “life waiver of premium.” Insureds and claimants do not have to pay disability premiums once their disability claims are approved. By the way, Life Waiver of Premium provisions can exclude premium payments for disability even if the life policy is underwritten by another company. It’s always a good idea to check your life policies to see if they have a Life Waiver of Premium for total disability.

Are insurance field interviews HIPAA protected?

Absolutely not. In fact, all records held by disability insurers are not protected either. Disability insurers are specifically excluded in the law as HIPAA “covered entities” and therefore, files at Unum or CIGNA, for example, are not HIPAA protected.

Again, even though Unum’s Authorizations are HIPAA approved, the auths themselves say that once the information is released it loses its HIPAA protection. Although HIPAA laws do not include disability claim protection, the medical records forwarded to insurers are protected. But again, once you sign an authorization releasing the records the first time, they lose HIPAA protection.

HIPAA actually doesn’t provide all that much protection for privacy of medical reporting. It just sets guidelines for the electronic transmission of medical records or medical information. This brings up the argument as to whether doc-to-doc phone conversations are HIPAA protected. In my opinion, they are, and that’s why many treating physicians are now refusing to speak with insurance docs.

After roughly 25 years in the business I am absolutely convinced that one of the reasons why insurance companies harass treating physicians with vexatious requests for information is because what they get back is not what they need, or are looking for.

Most treating physicians are very close to their patients and remain supportive during every phase of patient disability. Despite the fact that they are now required to fill out forms from every possible source (SSDI, Worker’s Comp, Private Disability, Personal Injury Litigation etc.), they do the best they can while trying to do their real jobs of providing patient care. The physicians I have dealt with on behalf of my clients have been totally supportive, and it is obvious they care about the health and well-being of their patients.

However, while I am extremely grateful to the physicians who take the time to  support disability correctly, there are some physicians who continue to regard time spent in filling out forms as a waste of their time. All disability claims are paid or not paid based on the quality of medical information sent to the insurance company. And, while insurers are busy doing everything they can to find ways to deny claims, it is now more important than ever for physicians to report the totality of patient impairment, and do a really good job.

DCS, Inc. specializes in assisting treating physicians to report medical disability wisely. Although I can’t go into a great deal of my proprietary strategies in a public forum, here are a few items physicians should be documenting on a regular basis.

  • Diagnoses, both primary and secondary with ICD-10 codes.
  • Prognosis.
  • Statement as to whether patients are at MMI.
  • Details concerning the physician’s treatment plan.
  • Medical restrictions and limitations. (Activities patients may never do, versus activities they may do, but only to a limited extent.)
  • Physicians should always provide what I call a “disability statement.” If the patient is “totally and permanently disabled”, the physician should say so.
  • Physician statement regarding exercise, activity and that it is recommended as part of a viable treatment plan.

Statements from physicians such as, “No work”, or, “Patient is disabled”, is not sufficient to support private disability. The doctor needs to provide much more detail about why his/her patients are unable to work. Of late, I’m hearing physician comments such as, “What does it matter? Insurance companies don’t pay attention to me anyway.”

Although this observation may have some truth to it, insurers do pay attention to medical reports if only to try to find ways around them. Strong, well-documented medical reporting makes it more difficult for any insurer to challenge disability claims.

I also find that some patients are reluctant, or afraid to communicate what is needed to their treating physicians. I can understand this since some physicians fly by during consultations because they are so busy, particularly in the larger physician facilities. It’s hard to try to discuss disability forms when physicians give their patients 5 minutes of follow-up office time.

Physician reporting can be improved when patients also take the time to discuss why they feel they are unable to return to work. Treating physicians are NOT mind readers and shouldn’t be expected to conjure up medical restrictions and limitations relating to jobs or occupations when needed. DCS recommends that insureds and claimants show their treating physicians job descriptions and explain why they are unable to do certain things.

Bottom line, physicians who do not take the time to do a good job reporting impairment are repeatedly harassed by insurers to provide more and more information.

Medical reporting is a priority for private disability.

 

 

 

 

 

One of my clients received a request from Lucens, Unum’s newest SSDI file chaser, to sign a form called “Authorization for The Social Security Administration To Release Information.” On the bottom right of the Authorization is “Form SSA-L88-OP1 (06-2014).”

In examining the form carefully, it appeared to me that something was very, very wrong. To begin, the Social Security Administration doesn’t place its form numbers on the bottom right, but the bottom left of all of its forms. Second, if you notice all SSA forms have an “Approved OMB No. at the top right of the form. And finally, no SSA form has bar codes on the bottom and right side of the page; and when I searched for the form from the SSA.gov page it wasn’t to be found.

Last year I wrote to SSA requesting to know why Unum was allowed to use its own form CL-1155 to request SSDI files. SSA responded that any authorization can be used if it meets the SSA Guidelines for Authorizations. I had no objection to that because Unum numbered its Form CL-1155, and never misrepresented its proprietary form SSA form with an approved OMB No. In fact, this was good news since DCS, Inc. could create its own form for client purposes.

However, the Lucens form uses an SSA number and is suggesting to insureds and claimants that the form is an official federal form when it is not. This kind of deception really irritates me because it isn’t necessary. Lucens could number it’s form differently, the same way Unum did and no one would be led to believe the Authorization was a real SSA form.

Please don’t be misled into thinking the Lucens Group Authorization is an official SSA form because it isn’t. It appears to me Lucens created it own form which is OK as long as the company doesn’t format it to deceive insureds.

Let me remind claimants that they do not have to sign any Authorization giving Unum permission to obtain their SSDI file. You are permitted to keep this information private. If you are harassed about it, pick up your phone and call your federal Congressman for assistance. At best, don’t be misled by the Lucens Group form; it isn’t an official SSA form even though it’s numbered to make you think it is.

Not a great start of confidence in Lucens as Unum’s new file chaser.

 

 

 

 

 

Friday Q & A

How can I challenge an insurance neuropsyche test?

Anytime an insurance company asks you to present for a neuropsyche test it is very important that you also either retain or inform your own neuropsychologist that you would like to obtain the actual test booklets and raw data (the tests themselves), for independent review and comment.

Although the  insurance industry tends to place neuropsychological tests in an “objective category”, the results clearly are NOT objective. Each insurance evaluator chooses a “battery of tests”, administers them, and compares responses to normative statistics and values in the national economy. Finally, the evaluators render an opinion as to what the results mean. Clearly, neuropsyche tests are NOT objective measures of disability, cognition, somatization, or malingering and should not be allowed to stand alone in anyone’s disability file.

Copies of test booklets, and raw data should be provided to your own independent evaluator for comment and rebuttal. If this is not done, the results will be presumed to be accurate and will stand in the record. All IMEs, whether neuropsyche or not, should be provided to treating physicians for rebuttal. Absence of comment from your physicians is presumed to be in agreement with the IME reports.

What is the percentage of income that IDI policies pay?

Individual Disability Income Replacement policies do NOT pay based on a percentage of pre-disability income. IDI policies always pay the “scheduled amount” indicated on the cover sheet of the policy. Therefore, IDI insureds are buying a fixed benefit (scheduled amount), with the opportunity of Future Option Increases at various intervals along the way.

People sometimes confuse ERISA Employer Group benefits that pay most typically 60% of pre-disability earnings with IDI policies that pay a fixed scheduled amount. IDI insureds may choose a level of coverage as long as the underwriting of the benefit doesn’t exceed actuarial guidelines for overinsurance.

In contrast, ERISA Plans pay a certain percentage of pre-disability earnings and employees may not choose their level of benefits except if the Plan is a welfare Plan and includes several levels of payment such as 50%, 60% or higher. Some employers may offer supplemental “buy-up” Plans as well, but benefits are always a percentage of prior income.

I can’t get ahold of anyone at Unum. Is Unum still a company?

I presume Unum is still a going-concern, however, I have been hearing from others how difficult it is to find someone to speak to. Settlement specialists are non-existent, and even attorneys are finding it difficult to get to the right people.

Unum has been chaotic for quite some time now. The company continues to terminate groups of employees while outsourcing a good amount of the claims process to other companies, and countries. There is very little about Unum that is reputable these days and no one should be surprised when they can’t find someone to speak to. I’m guessing it’s much worse than that.

Who is G4S?

G4S is an investigative agency retained by insurers to conduct surveillance and field interviews. Additional information about the company can be found online, but in short, insurers hire the company to conduct investigations.

Although the name G4S sounds like “you’re in for it”, I’ve found the company to be your everyday run-of-the-mill insurance investigative resource.

 

 

 

Guardian seems to be staying in the news lately as the company’s focus on “credibility investigation” reaches over-the-top levels. While no one disputes the right of any insurance company to fully investigate claims, Guardian’s practices exceed investigation levels that would normally be required to determine insureds are “unable to perform their own occupations.”

A good case in point is the insured who was injured as a result of an automobile accident several years ago and who recently claimed disability due to various shoulder muscle tears etc. According to the information I have Guardian’s investigators actually hunt down the driver of the “other car” who promptly said, “the accident was no more than a fender bender and no one got hurt.”

Seems to me the “at fault” driver might have a conflict of interest in reporting a “no one’s hurt” accident, but I have to wonder why Guardian took this line of investigation. If the insured’s medical information certifies the insured’s inability to perform as a dentist today, then what would it matter what the driver of the other car reported?

Guardian also tends to interview ex-spouses, a deliberate attempt to sully insureds’ reputations and credibility. Investigators “show-up” to interview peer workers, or accost them in parking lots with requests for written statements. There does not appear to be any logical reason to investigate the way Guardian does, and in my opinion, it crosses the line of prudent, normal and customary disability claim review.

Guardian’s investigations always seem to focus on credibility in lieu of whether or not insureds meet the definitions of disability in their policies. The company performs complex financial calculations regarding “residual” disability even when insureds are not residually disabled. Misrepresentations of policy provisions are immediately apparent, with little expectation of Guardian reversing its position.

Guardian’s claim investigations obviously have set priorities to investigate to deny rather than investigate to pay. This is the primary difference between fair and equitable insurers and those who seek to discredit insureds at all costs. DMS, Disability Management Services, is also a company who often investigates “credibility” in addition to contract provisional standards.

I can’t tell you what’s happened to Guardian in the last several years, but it’s all been downhill. Professionals looking for private disability and business protection coverage should look more toward Northwestern Mutual products and avoid Guardian’s insane investigations.

 

In nearly two decades Unum Group continues to fail in creative imagination! When caught red-handed by the multi-state regulators in 2004, Unum didn’t improve it’s claims practices, but became an old mare of a different color and continued its abuse of authority under different titles, names and practices.

One of Unum’s old “scams” being reported is to send files for financial review only to have them emerge from Aesop’s Fables accounting methods alleging claimants owe exorbitant overpayments, sometimes in the hundreds of thousands of dollars.

A recent case reported to me describes a claim situation where Unum alleges a claimant owes $316,000 because his employer changed its group plan from a $10,000 max benefit to a $6,000 max benefit. Upon further investigation I found out that Unum alleges the claimant’s employer specifically wanted the change “retroactive.”

First of all, let’s take a look at a few things we need to know here:

  1. Employer’s can only change the writing of their group Plans during the annual enrollment period. Plans may not be changed at any other time during the year.
  2. When employer Plans ARE changed, either a written Amendment is issued to the old policy with an effective date, or a new Plan is issued with a new effective date.
  3. The policy in effect as of the claimant’s date of disability is the policy that is adjudicated. While employers may in fact change the provisions of their Plans in the future, the new changes do DO NOT affect a prior policy.

Disability policies are subject to contract law. Therefore, when a claimant files a claim, the policy that was in force as of his/her date of disability is the policy that is used for the duration of the claim. New Employer changes to future Plans with different Effective Dates of Coverage have no effect on prior claims.

Therefore, if the claimant in this case has a Plan with a $10,000 max benefit with an Effective Date of Coverage prior to, or on his date of disability, Unum cannot make any future employer changes to the Plan “retroactive” as it alleges.

This is a situation that makes me wonder if the individuals reviewing Unum claims are    competent or not. It’s not rocket science here – the policy in force as of the claimant’s date of disability is the policy that is adjudicated.

The malicious attempts of Unum to force claimants to repay money that is not owed, at least in my mind, is deliberate fraud. Unum immediately reduces monthly benefits to $0 to recover its alleged overpayments and claimants are caught helpless by a Robber Baron profiting from its own internal financial scams.

As an expert in this area, and also considering Unum’s “suspension” of benefits tactics, I suspect the company may have a cash flow problem. Why would the company “suspend” benefits for little cause, and also allege large overpayments in order to reduce benefits to $0? This isn’t a financial reserve problem, but a cash flow problem.

Anyone who finds themselves victimized by Unum’s financial scams should insist on seeing calculations, spreadsheets, and other data that proves Unum has a right to recover money from their benefits.

In my opinion, this is insurance fraud and is well-deserving of a RICO case involving racketeering. It’s not fair to claimants, and it needs to be addressed in the courts of public opinion.

 

Have you ever wondered how Unum and other insurers seem to find out things? Not only are insurance companies hacking into Facebook, Twitter and LinkedIn accounts, but they seem to have other ways of finding out information about you and your claim. Insurers all stick together regardless of whether their actions are ethical, legal, or not.

Recently, an insured who was injured in an accident received a third-party settlement in which was written a non-disclosure statement. Suddenly, he gets a letter from Unum demanding repayment because his policy offsets “third-party settlements.” Apparently, Unum was sent a copy of the insured’s settlement check either by Traveler’s or State Farm.

In my mind a non-disclosure statement actually means non-disclosure. My guess is that since Unum knew about the insured’s injury they probably contacted both Traveler’s and State Farm and asked to be copied on any settlement. Or, Unum could just have contacted the insurers and asked for information. I’m not discounting other “investigative” means Unum has either, but either way, non-disclosure is still non-disclosure.

It’s not that the insured wanted to hide anything either. But, Unum found out about the settlement quickly which means it already had “information and search” available to it. Upon further investigation it was discovered Traveler’s or State Farm sent Unum a copy of the settlement check. They would not have done this if Unum hadn’t inquired or had an inquiry set up.

Other leaks often come from predictable sources such as ex-spouses with axes to grind, or neighbors when Rover winds up too often on their side of the fence. Today, it seems as though everyone is looking for wrongdoing even when there isn’t any.

Insureds can find themselves in trouble when other family, friends and former co-workers see them loading cases of soda in your trunk and call the Social Security Administration to make a report. (This actually happened.) Today, SSA does have the means to conduct surveillance and place any recipient under investigation.

Unum insists on obtaining SSDI files when claimant are not under any obligation to provide them. There is an information war going on between insurers and insureds because insurance companies believe everyone is filing claims for secondary gain and not keeping them informed.

Insureds and claimants should consider that there isn’t any information out there that can’t be had – legally or illegally. After all, investigators aren’t supposed to peep in your windows but they still do – they just communicate the information verbally and never put anything illegal in writing.

Don’t be surprised when insurers pop up with information you thought was unobtainable. Anything is possible in today’s insurance environment.