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Friday Q & A

What is Unum’s internal policy regarding the management of mental health claims?

Unfortunately, Unum’s internal management of mental health claims has progressed from DSM-5 listings to declaring other impairments, such as cognitive deficits, Lyme disease, and chronic pain as “self-reported”, or “subjective”. As a result many other physical diagnoses are limited to 24 months just because Unum says so.

Unum’s abuse of the Mental and Nervous provisions in its Plans and policies is no surprise, particularly to regulators in California. From 2004-2008 regulators attempted to hold Unum accountable for M&N claim abuse, but it looks like Unum has resurrected closing down claims anytime it alleges claimed disabilities are “self-reported.”

“Self-reported” is defined as any claimed impairment for which there is no objective evidence test or lab process to verify what you say you have. “Clinical diagnosis” means patients are diagnosed with a disease based on their physicians’ history of consultation and personal observation.

Unum’s internal process is to initially approve mental health claims for depression, anxiety, panic attacks etc. for a period of 12 months. After 12 months all hell breaks loose as Unum begins to question “why” insureds are not getting better. Surveillance, field visits and IMEs in the form of neuropsyche tests are requested in an effort to discredit M&N claims after 12 months.

Let’s not forget that Unum will relentlessly continue to request actual psychotherapy notes in order to “snatch” key phrases from what would otherwise be classified as personal and private information. Most mental health providers are now refusing to release treatment notes since they are not written, nor are they intended to support or not support disability claims.

To the extent Unum can, it will continue to allege that other impairments are self-reported to limit benefits to 24 months. In some cases insureds are not capable of mentally managing Unum’s abuse and should seek assistance.

My Unum check is late. What should I do?

Unum is the only insurance company that seems to have a problem with late checks over the holidays. Most of Unum’s staff take their PTO time and “forget” to approve payments due before they leave. This is the one and only time when I recommend a phone call to customer service inquiring, “Can you please tell me when I can expect to receive my check?” Do NOT say, “Why am I not getting my check?” Just ask when you can expect it!

As I said, no other insurance company deprives its insureds of benefits during the holidays. If you check is late, call and find out when you can expect to receive it.

I’ve sent medical records three times to Unum. It still says it hasn’t received them. Now what?”

I know. Apparently, Unum Group is now as inefficient as Aetna, and CIGNA when it comes to losing and misplacing documentation it receives. I’ve discovered myself that Unum’s claims handlers have absolutely no idea what is and what isn’t in the claim files. Multiple requests for the same information are sent out to insureds who are required to re-send valuable information. Physicians are becoming more and more wary of accepting patients with disability claims because of Unum’s direct harassment that never ends.

Claimants who send their own information should send by either Priority Mail or Priority Mail Express with Signature Confirmation. (What is amazing is that Unum never seems to lose records sent this way.) If faxing, always print out a paper confirmation that records were confirmed received.

Unum used to have much more control over its administrative process but in the last year or so it has been lowered to Aetna’s and CIGNA’s chaotic system of claim review. Unum’s claims review process is negligent at best, another thing the company should not be proud of.

My Unum claims handler doesn’t seem to know very much. Should I be worried?

Several things are in play here. Unum continues to engage in gender and age discrimination to the point that tenured and experienced employees are frequently fired. New, younger, and alleged healthier individuals replace knowledgeable claims staff.

New U-numbies are essentially 1 French fry short of a Happy Meal in terms of understanding “risk management” and the adjudication of disability contracts. In addition, new claims handlers are deliberately dumbed-down to not know anything other than doing what they are told. Remember, it’s Unum’s way or the highway, allowing more and more fry less Happy Meals to touch claims.

My recommendation is to make sure you are communicating with Unum only in writing so that its poor service and “stupidity” can be documented for the record. Actually, this is true for every disability insurer in the country.

 

 

 

 

oopsAlthough in the past Individual Disability “own occupation” policies were often sold as  “better than sliced bread”, today they barely put food on the table.

In the 70’s and 80’s insurers risked their companies believing that professionals, such as doctors, dentists and highly paid executives would not file claims for secondary gain. This risk turned out to be a disaster.

At the time it was not anticipated that HMOs, PPOs etc. would enter the scene and making it very unprofitable for physicians, and other health professionals, to maintain their practices, or even want to. The nature of health care changed restricting billing, and setting up fixed fees for certain procedures.

Due to the billing innovations of the new health care system, professionals began filing disability claims on own occupation polices. As a result many insurance companies were forced out of business, but the remainder developed deliberate strategies to prevent excessive payouts for “own occupation” to save its own skin and reputations.

“Own occupation” disability IDI was purported by unknowledgeable agents to be the holy grail of disability products –  “If you can’t work in your own occupation you can go do something else and still get paid.”

Although this is technically true, it isn’t the whole truth; and, it remains increasingly frustrating for insureds today who never did understand their policies when they purchased them and who now believe they can work and still get paid 100% of their scheduled benefit for total disability.

Although most IDI insureds actually paid additional premium for “Residual Disability Riders”, they obviously missed the significance of what they really meant. Residual disability provisions and riders pay a proportionate loss benefit {under certain conditions} to those who are working in their own, or in some contracts in “their regular occupation, or in another occupation.”

This means if an IDI insured is working in their own or another occupation they are paid residually. Hence, the “own occupation” definition is relevant only if the insured is not working at all; the “residual” Rider comes into play when working part-time or full-time performing the same, or another occupation. Most contracts require insureds to have at least a 20% earnings loss in order to qualify for residual disability.

In reality, an “own occupation” definition is “qualified” by Residual Disability Riders when they exist. If an IDI insured is working, they are said to be “Residually” paid and qualify for benefits under the “residual contract provisions.” Suddenly, own occupation becomes applicable only if insureds aren’t working at all.

Hence, when IDI insureds want to insure payment after returning to work in some capacity they purchase “Residual Riders”, without realizing there are now two definitions of disability in the contract – “own occupation” for total disability, and “residual” for returning to work.

Also, IDI insureds tend to wait long periods of time before filing claims – sometimes years. Although as a rule IDI policies cannot be denied for late filing, they can be denied for “prejudice”, meaning the insured waited so long to apply that he/she actually “prejudiced” the insurer’s investigation of the claim. Insurers are infamous for saying, ” An IME today is not the same as an IME in 2011.”

When I ask IDI insureds, “Why did you wait so long to apply for benefits?” I am told, “I thought I would be able to return to my job or business”, or “I didn’t know I had this policy.” Contract provisions typically require IDI insureds to file claims within 90 days after any claimed period of disability, or up to 1 year for mental incapacity. Most states now require insurers to “prove” prejudice before denying claims.

IDI insureds also have the mistaken impression that once insurers receive their application paperwork they will approve and pay claims immediately. IDI insurers are not subject to ERISA and therefore insurers may take as long as can to investigate and pay claims, often demanding more and more paperwork.

It is essential for IDI insureds to file timely claims with complete and accurate information from the beginning. Physicians are required to send in MONTHLY P&Ls AND CPT codes. Very few physicians can actually come up with MONTHLY information because it’s not kept or generated from their software on a regular basis. This makes applying for IDI disability a real untimely hassle.

There are many other errors involved in filing IDI beyond the scope of this article. If you have any questions concerning the process, please feel free to give me a call to discuss.

It may be that you need assistance in order to file and maintain a successful IDI claim, particularly if you don’t understand it, or have been told inaccurate information about “own occupation” and “residual riders”.

 

Holiday Naughty List

Several times this month I’ve received phone calls asking me to recommend insurers for both Group STD/LTD and Individual Disability. While the disability insurance industry is corrupt as a whole there are insurers who engage less in bad faith than others.

Here is my top 20 ranking for 2017 beginning with the worst insurers.

 

 

  1. Unum Group
  2. Prudential
  3. CIGNA
  4. Met Life
  5. Aetna
  6. The Hartford
  7. Mass Mutual
  8. Sedgwick/The Reed Group
  9. Guardian/Berkshire
  10. Disability Management Services, Inc.
  11. RMS
  12. Ohio National
  13. Mutual of Omaha
  14. Lincoln Financial
  15. Liberty Mutual
  16. The Standard
  17. Standard Reliance
  18. Aflac
  19. Principal
  20. Northwestern Mutual

While there are no real “better” group STD/LTD insurers, the Individual Disability market shows both Principal and Northwestern Mutual to be fair reviewers of individual disability claims. Congratulations to NWM and Principal for continuing to perform objective claim reviews in 2017!

In my opinion, the “Top 10” listed are not fair disability claim reviewers and should not be considered to be fair in any aspect of claim investigation.

 

 

Readers have probably read many of my articles on this blog that “Prudential and The Hartford do not fall far from the Unum tree.”

This probably stems from the fact that The Hartford is filled with old Duncanson & Holt (a former subsidiary of Unum Life) executives while Prudential hired the overflow of terminated employees from Unum – not good ones mind you.

All three companies: Unum, Prudential and The Hartford appear to manage claims with like mind and engage in many of the same unfair practices. In some cases, they use the same language in their written communications and follow the same patterns of Plan and policy misrepresentation.

When I heard this morning that a Prudential claims handler actually said, “Oh, we don’t do that sort of thing here at Prudential. I used to work for Unum, and we operate very differently”.

My first thought was that the “proof is always in the pudding” so to speak. Prudential’s mantra of unfair patterns of practice is well-known to claimants who suffer through a claims review procedure that is somewhere between corrupt and well-defended deliberate negligence. In fact, in my opinion, Prudential is second in egregious claims practices after Unum Group,.

Prudential has a history of using Registered Nurses without specific specialty to review patient notes and puts forth the reviews as back-up for claim denials. Claims with considerable financial reserve deserve more than an un-specialized RN review before denying claims.

In addition, the company also insists on obtaining mental health records even when  psychologists and psychiatrists refuse to release them. Penalizing claimants for the refusal to release actual psychotherapy notes is a Prudential “pattern of practice” it has never been held accountable for.

Even when psychotherapy notes ARE disclosed Prudential’s RNs engage in some of the most egregious misrepresentation I’ve ever come across in the 25 years I’ve been working in disability claims. For example, if the therapist refuses to mention the claimant’s “affect”, or doesn’t administer “other psychological tests”, all other information contained in the patient notes favorable to the insured is tossed and not considered.

In one particularly awful Prudential review, it was cited that patient notes mentioned a “non-working boyfriend who visited and did nothing to help support the household.” It was Prudential’s opinion that housing a “worthless” boyfriend caused the claimant to do all of the work and her claim was denied.

Prudential is also known for using “shady” third-party resources to review its claimants’ records. Companies who openly profess “assisting insurers with their goals”, and who “teach” employee neuropsychologists how to test to deny claims aren’t capable of providing “independent review” although Prudential’s management continues to profess “good faith and fair dealing.”

In addition, due to the cross-over of Unum’s management to Prudential “old Unum MDs” are often paid to perform IMEs and do peer reviews. These well-known claim killer insurance defense physicians cause extreme claimant hardship by using the same old logo to provide insurance defense with the illusion of credible reports.

Finally, Prudential is also famous for its say nothing six page letters to claimants, failure to answer questions asked, alleged lost paperwork and time/date tactics to avoid paying LTD. For example, Prudential often denies STD claims within a week or two to maximum duration so that it can allege the Elimination Period for LTD was not met.

Given all of the above you can well imagine my reaction when I heard a Prudential rep’s comment that “it doesn’t do that.”  Interestingly, Unum uses the “we did nothing wrong defense” all the time. The Hartford never attempts to defend its unfair claims practices but continues to engage them anyway.

The truth is, neither Prudential, Unum nor The Hartford “walks the talk” and they continue to collude with similar unfair claims practices and communications. The  most recent example of collusion is Hartford’s requests for SSDI 1099s, copying Unum’s Lucens debacle to locate pennies of overpayment.

Are all insurance claims reps brainwashed into thinking their respective insurance companies are doing the right thing? Typically, it takes an insurance claims handler about a year to lose the INSURANCE SPEAK and think clearly again.

Most claims handlers, however, are fully aware of what they are doing despite the false honesty in their statements.

 

 

Unum In The News….

You're Fired2

Unum Firings – No Job Security

Unum insiders continue to report the company is still terminating employees, mostly women over 50. Unum is well-known for its terminations of mature women spanning a decade or more. The company’s mantra is to target females over 50 by padding personnel files with issues alleging “poor performance.”

Unum isn’t the company for females looking for job security. Current employees continue to report lack of upward mobility for most claims personnel. In addition, Unum does not approve employee FMLA and STD claims even for its own. Instead, employees who go out on medical leave are quickly disposed of through the auspices of “poor performance.”

Unum is NOT a good place to work since claims handlers are repeatedly forced to watch their backs in addition to performing jobs that are extremely stressful. My impression when I actually worked for the company was that those who picked the toenails of managers were promoted and pushed ahead even though most were one taco short of a combination plate! Hence, Unum’s frequent lack of knowledgable leadership.

Unum’s continued fast forward to outsource most work leaves little expectation of job security for those who remain employed, at least for the time being.

PA1959Pennies From Piggy Banks

Unum insiders are also reporting the company’s “hunt and peck” for SSDI monies owed may be including COLA specifically excluded as an offset in all ERISA Plans. It’s unclear how complicit Lucens is in the scheme to find “a dollar here, a dollar there” overpayments.

Claimants should always request Unum “to prove it” [overpayments] before agreeing to pay back any money. Requesting SSDI 1099s does not separate gross benefit from COLA; therefore, it’s a mystery why Unum even requests the 1099s.

Still, there is usually no logic to Unum’s schemes other than to bolster profitability. Unum should always be asked to “put up, or shut up” when it comes to allegations of owing money. The Financial Department’s efforts to hunt down pennies out of SSDI award piggy banks is an indication of how badly the company may need the money.

“It’s All In Your Head”

All in your headThere are also recent reports that Unum Group fully intends to use the “self-reported” language in its Plans and policies to deny claims particularly for fibromyalgia, chronic fatigue and possibly memory and cognitive issues, Lyme disease, depression, and any other impairment it can throw under the bus.

Anytime a disability insurance company reviews claims with an objective of denial rather and approval, it can be reasonably said the company is engaging in unfair claims practices. To seek out legal support in various states that will support such tactics is a deliberate effort to target certain impairments and classify them as “self-supported.”

Fibromyalgia and chronic  fatigue have always been challenged (particularly in the UK) as “fake” or “somaticized” impairments. The new DSM 5 suggests that anyone who is worried or preoccupied with anything that’s wrong with them is also crazy. Clearly, one has to question the classification of somatic illness when it’s defined as worry, preoccupation and overindulgence with symptoms imagined or real.

Seems to me the current DSM 5 definition of somatic syndrome leaves the door open to classifying nearly everyone as mentally ill. Needless to say, it looks as though Unum is back to its nasty tricks of alleging physical disease is “all in one’s head” in order to avoid payment.

corporate theft SSDI Hold Ups For Repayment

Unum’s Financial Services Department does not get a gold star when in comes to chasing down SSDI overpayments from claimants. Representatives are pushy and demand repayments via threatening letters and demands for repayment.

This particular issue was brought to my attention when demands for repayment of SSDI money not received crossed the line of fair review. First was a situation wherein Unum’s reps attempted to use, “Well, SSA usually makes a decision in 4-6 weeks and your application is over 3 months old….we’re going to offset your benefit with an estimate” as a threat.

Second, Unum demands repayment under threat of offset even when the claimant hasn’t yet received any money from SSA. Claimants cannot pay what they do not yet have, simple as that. Yet, claimants are often penalized with offsets prior to receiving any actual money to pay back.

Is Unum really that hard up for money? The company’s new tactics and objectives are about as far away from good faith and fair dealing as they can get.

 

 

MetLife is by no means the only DI insurer that abuses policy provisions to limit benefits to age 65 and avoid paying Lifetime benefits.

However, recently it came to my attention that MetLife is engaging in unfair claims practices in order to avoid payment of Lifetime benefits.

Policies that stipulate Lifetime payouts for Total Disability but only to age 65 for Residual claims are consistently “alleged” to result in the payment of benefits “residually” in order to avoid payouts for Lifetime benefits.

This is particularly true of the typical DI insured who also has investments in passive income such as rentals, land development and other partnerships. Although passive income is usually reported on Schedule E of the US tax return, legal tax avoidance in some cases may place portions of the income on Schedule C as self-employment income – a huge mistake for those with private disability claims.

MetLife’s mantra is to allege insureds had a dual pre-disability occupation such as a Dentist and partner in rental management. Therefore, any income from rentals appears as though it’s earnings and not passive income. “Earnings” results in the payment of Residual disability and therefore benefits are limited to age 65.

Are you following MetLife’s logic? The insured is limited to benefits to age 65 because he has “passive rental income” and can be said to be “residually disabled.” Although passive income is most often derived from investments, rents, royalties, copyrights etc. most insurers look to other investments to allege “residual earnings” even when they have to pay 100% benefits, residually for passive income losses.

Unum does the same thing but in distinguishing between Sickness and Injury. Both insurers are engaging in deceptive claims practices involving interpretation of information and contract provisions (without ERISA discretionary authority I might add.)

The solution, in the form of preventing this problem begins in the planning stage before DI policies are purchased as part of a total family future portfolio package. Policies that distinguish maximum duration for Total vs. Residual disability should be suspect to the point of limiting alternative passive income. Another solution might be to add Lifetime Riders for both Total and Residual Disability, and Injury and Sickness.

It is extremely important for DI buyers to consider future possibilities before purchasing DI products. In addition, it is clear that insureds should be very careful of passive income and how it is reported on yearly tax returns. The door is already open to abuse by most DI insurers in those policies that distinguish between Total disability and Residual.

Never leave it up to Unum to ignore the opportunity of denying or limiting benefits for alleged “self-reported” impairments such as Fibromyalgia and Chronic Fatigue.

New information suggests Unum Group is testing the legality of denying FMS claims under the “self-reported” language in its group ERISA Plans. This is the same company that has petitioned the U.S. Department of Labor NOT to adopt the new proposed ERISA guidelines in 2018 that would be extremely supportive and beneficial to many claimants.

Unum Group’s history of targeting and denying legitimate claims continues to contribute to its poor public perception of unfair claims practices. However, when it comes to the classification of FMS and CFS, Unum has had a great deal of help in discrediting FMS as totally impairing for disability purposes.

In October 2015 the new Diagnostic Manual, or DSM 5, created a new category  called, “Somatic Disorder Syndrome” that describes impairment symptoms of “imagined” etiology, or exaggerated syndromes literally that are all in one’s head. While Unum, and other disability insurers, were already screaming “it’s all in your head”, in 2015 a new validation of imagined syndromes emerged on the scene.

 To make matters worse, in ICD-10, the latest version of the International Statistical Classification of Diseases and Related Health Problems, somatization syndrome is described as:

“The main features are multiple, recurrent and frequently changing physical symptoms of at least two years duration. Most patients have a long and complicated history of contact with both primary and specialist medical care services, during which many negative investigations or fruitless exploratory operations may have been carried out. Symptoms may be referred to any part or system of the body. The course of the disorder is chronic and fluctuating, and is often associated with disruption of social, interpersonal, and family behaviour.”

In effect, the DSM 5 removed any possibility of defending FMS and CFS as “physical impairments” since all insurers were more than happy to jump on the “mental and nervous bandwagon” to limit benefits to 24 months.

In fact, thanks to the DSM 5, insurers now have defensible arguments for defending FMS as a purely mental disease. Therefore in my opinion, insurers may have a point in limiting FMS claims to 24 months under the mental and nervous provisions of group ERISA Plans.

“Self-reported” might be too large a denial jump, however. “Self-reported” means the so-called impairment is reported solely by the patient since there are no objective tests to confirm the existence of disease other than what is reported by the patient.

While lawyers are defending that there are no objective evidence standards in employer Plans, in my opinion, “self-reported” provisions are actually back-door descriptions of “objective evidence standards.” If Unum can deny claims for impairments it alleges are “self-reported”, it is also logically reasonable to say the company pays claims for which there is objective evidence. Alas, a definition of “objective evidence” by default, and in the back door.

However, the DSM 5 is the real culprit. Are insurers prepared to deny claims for all of the “syndromes” identified in the DSM 5? You bet they are. In any event, it’s been noted that Unum is once again hell-bent to deny and/or limit benefits using the “self-reported” language in their Plans.

Unum never misses an opportunity to deny claims, but the DSM 5 and ICD-10 were not helpful to claimants in supporting FMS as a credible physical impairment.

Today, it’s just “all in your head.”

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