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SSDI Isn’t Welfare

So many times insureds and claimants are reluctant to apply for SSDI because they believe that it is a “hand-out”, or that at some time in the future they may be able to return to work. The notion that SSI, SSDI, and SSR are government handouts indicates how uniformed the American public is regarding what they actually pay for.

The Federal Insurance Contribution Act (FICA) provides for a mandatory tax deductions that pays for SSI, SSDI and SSR. American employees pay this tax during their entire working career in anticipation of receiving benefits they qualify for in the future.

For 2017 employees must pay 6.2% in SS taxes, 1.45% for Medicare up to an annual wage of $127,200. Please note, that highly paid employees earning more than $127,200 do not pay FICA taxes. Therefore, the most that any employee is forced for pay for FICA and Medicare is $7,886.40. Payment of FICA never ends for employees earning less than $127,200.

However, the burden placed on employees is not the total liability. Employers must also contribute the same tax rates on your behalf. Therefore, FICA taxes are paid both by employees AND their employers to the tune of 12.4% for SS, 2.9% for Medicare, a total of 15.3%. Self-employed individuals pay both the employee and employer’s FICA and Medicare taxes, a large financial burden for being in business.

“Welfare” is something individuals receive for free such as food stamps, subsidized housing, WIC programs etc. Conversely, SSDI is funded by FICA and Medicare taxes paid for by employees and their employers, and therefore it is an “entitlement”, not welfare. Individuals qualifying for, and receiving SS benefits are receiving a return on their contributions.

Individuals should always file for SSDI as soon as it is obvious that returning to work is unlikely to happen in the next 12 months. To be eligible for SSDI payment, disabled persons must have worked at least 5 out of the last 10 years.

Anthony (not his real name), waited 9 years to file for disability even though he was unable to return to work for medical reasons. He won’t be eligible for SSDI because he waited too long to apply. Anthony would actually have to go back to work and earn 20 credits (4 credits per year) in order to qualify for SSDI.

The American work ethic that causes people to believe that SSI, and SSDI are welfare is entirely unfounded. SSDI is a federal entitlement workers and their employers pay for. It isn’t a hand out. Private disability insurers take advantage of the entitlement to limit their own liability for the insurance they sell, then renege on the promises they make.

Those with private disability insurance should not “feel bad” about applying for SSDI because there are advantages to doing so. Depending on age, qualifying for Medicare within two years is a bonus.

My suggestion to American workers is to research for yourself the debt burden you’ve paid through FICA and Medicare taxes during your working career. SSDI is NOT welfare, but a federal entitlement you and your employers paid for.

If you are eligible for benefits, you should apply, and as soon as possible.

 

 

 

Friday Q & A

Does it matter if I pass or fail my neuropsychological test?

This is actually a very good question because insureds often have grave misconceptions about neuropsychological tests.

To begin, neuropsychology evaluations are NOT pass or fail. A battery of tests, (also not pass or fail), is chosen and administered by the evaluator. The results of the raw data (tests) are compared to normative scales/values and then subjectively evaluated. In other words, the evaluators give their opinions as to what the results of the tests mean. It is for this reason that I do not consider neuropsychological evaluations as “objective review.”

So many insureds are worried about “passing or failing” the evaluation when the test does not do that. A neuropsychological test is a qualifying evaluation to determine mental and cognition problems, impaired memory, malingering, imagined symptoms, and a whole host of other mental and behavioral issues. It is never a question as to whether one passes or fails, but whether the individual exhibits signs of real or imagined disease.

Insureds may be equating a claim denial with a “failed test”, and benefit approval with a “passed” one. But, in reality neuropsychological tests are evaluative tools, not tests that are passed or failed.

I found Unum’s claims reps to be totally rude. What can I do about that?

Yes, I’ve been hearing that Unum’s reps are missing a few French fries from their Happy Meals lately. My experience tells me this happens when claims handlers are overly stressed to produce profit results that don’t exist.

However, information I’ve been receiving from inside Unum also indicates the company’s internal philosophy toward insureds and claimants changed to negatively presume everyone who files a claim is a fraud. New claims handlers are currently trained to “suspect” all information submitted.

Companies who support such negative perceptions of its own customers encourage rudeness, and disrespect among its employees. In my opinion, part of Unum’s problem is (and always has been) arrogance resulting from lack of state and federal regulation and oversight.

For the moment, however, we know that Unum is internally chaotic and negligent in administering claims. Rudeness from employees is, of course, an offshoot of that.

DCS, Inc.’s clients communicate with Unum only in writing thereby avoiding Unum’s nasty claims handlers and their rude comments.

Can I report Unum to my state insurance department? Will they do anything?

If you have an ERISA Plan and the jurisdiction of your policy is subject to ERISA, your state Department of Insurance may or may or may not help you. I recommend that you send your complaint to your state DOI and request that they do “a market conduct examination of Unum’s claim’s practices.”

The ERISA folks can also send a copy of the complaint to the regional EBSA of the US Department of Labor. The location and regional addresses can be found at the DOL’s official website.

I wouldn’t waste your time sending complaints to Unum. The company’s mouthpieces like Rick Joseph do not solve problems, but only respond with a 10-page “we did nothing wrong defense.” It’s a waste of time complaining to Unum.

 

 

Judging from the number of calls and emails I receive it’s clear those in the insurance industry are wondering what Unum is up to that is producing the amount of negligence and chaos now present in the company’s claims review process.

Unum’s unfair claims practices are no longer a matter of supposition but are obvious to those who have dealings with the company. Suspending benefits for no reason, rude and disrespectful claims handlers, continued firings of employees, removing internal departments and then cloaking that fact from other employees, outsourcing large amounts of work to third-party facilities or overseas, attempting to allege large overpayments are owed, using the settlement department (or Lucens) to unleash claim investigations, and finally terminating claims previously paid for long periods of time, 10, 15, even 21 years.

From what experts are seeing currently Unum now has three initiatives in operation to attempt to either deny more claims or reduce benefits to $0 to avoid payment of benefits that are legitimately due.

  1. Claim referrals to Lucens to obtain SSDI financial information that can be used to recalculate benefits and offsets for the purpose of conjuring large overpayments due and reduction of benefit amounts payable to $0.
  2. Using the settlement department (and, it is unclear whether Unum has also transferred this function to Lucens) to engage in extensive claim investigations also for the purpose of denying claims rather than settling them. Obviously, it’s cheaper for Unum to deny rather than settle claims.
  3. Reclassifying previously paid physical claims into mental and nervous impairments so that claims can be denied immediately or paid for only 24 months. Unum’s frequent requests to obtain SSDI Form 831 information and psychotherapy notes is for this purpose.

Unum’s insureds and claimants should consider that the company’s new initiatives are “deliberate” and have been engaged in enough to satisfy the definition of “pattern of practice.” DCS, Inc., in cooperation with litigating attorneys has been dealing with the issue of Unum attempting to collect on large “re-calculated” overpayments.

In my opinion, any insurance company (or its agents) that deliberately twist, or misuse generally accepted accounting principles and the concept of “continuity” to harm those it does business with is fraud, clear and simple. I know that there are many insureds and claimants who are receiving “letters from Lucens” and have no idea what to do with them. Others who have asked Unum for settlements are now in the midst of extensive investigations.

Simply put, it now appears that Unum is targeting claims to obtain all information relevant to “offsets” and is forwarding that information to Lucens for financial scrutiny. If this is incorrect, I’m sure the Internet snoops who forward information to Lucens will contact me as they have in the past. However, on the face of it, it does appear that Lucens is connected to Unum’s new target initiatives, and is either chasing the information and forwarding it to Unum, or is further involved in actually assisting with the new “re-calculations.”

Between 2001-2004 UnumProvident was severely criticized and reprimanded in the California Settlement Agreement not to abuse the Mental and Nervous provisions in its policies. The company agreed to change its claims practices and not back date 24 month limitations, but it appears Unum is once again abusing mental and nervous limitations by demanding the release of actual psychotherapy notes, especially for claims paid for long periods of time.

Psychologists and psychiatrists have long come to the conclusion that actual therapy notes are proprietary and are not written for the purpose of determining disability. Most mental health providers do NOT release actual psychotherapy notes and prefer to support disability in summary form (filling out forms and questionnaires.)

Apparently, therapists and mental health providers have rightfully come to the conclusion that disability insurers misrepresent information contained in psychotherapy notes and refuse to release records. Unum’s current requests for mental health records may prove not to be as profitable as they think.

Nevertheless, Unum is once again abusing the Mental and Nervous provisions in its policies. What is not surprising is that Unum’s bold steps to engage in “patterns of practice” adverse to insureds are obvious, open and deceptively arrogant.

Insureds and claimants should be aware of Unum’s tactics to engage in claims practices that are unfair, and in at least one case (M&N issues) has been determined to be egregious by the California Settlement Agreement.

If you have any questions about Unum’s target initiatives  to harm you and your claim, please feel free to contact me. We are already assisting clients who are now dealing with Unum’s unreasonable requests.

Disability financial reserves are generally defined as “a monetary estimate of what a claim will cost.” The reserve represents money set aside for the eventual payment of claims and is not otherwise available to pay operating costs such as salaries, expenses and other overhead costs. Since the financial reserve actually represents the future obligations of an insurer to pay the cost of claims, from an accounting perspective, reserves are classified as liabilities on the company’s balance sheet.

Financial claim reserves are clearly important in determining the insurer’s financial health. “Under reserving” suggests the disability insurer may not have sufficient funds on hand to pay future claims and presents a false picture of the company’s financial stability. Investment brokers who set insurance bond ratings as well as federal and state regulators look to insurance financial reserves to determine the financial ability of an insurance company to pay for future claims.

Although financial claim reserves can theoretically be said to be the future value or anticipated cash payout of claims, reserves generally include actuarial and historical experience data kept by each individual company. It is customary for insurance companies to hold several different reserve amounts. Some insurers include estimates for claim expenses in the reserve amount; others establish a separate reserve for the claim and a separate reserve for anticipated expenses and interest.

Therefore, most experts would agree to the following definition of insurance financial reserves: “Financial reserves are the amount of funds (or assets) necessary for a company to have at any given time to enable it, with interest and premiums paid as they accrue, to meet the financial obligation of all claims on the insurance in force.”

Although financial reserves are theoretically regulated by the state, one can clearly see that it would be in the best interests of the disability insurer to limit or “set aside” the least amount of financial reserves, preferring to use available cash to pay operating expenses, or to generate portfolio investment income to offset the cost of claims. Simply put, regulations require all disability insurers to set aside financial reserves to pay future claims creating a potential loss situation, but when disability claims with open reserves are then closed (or reduced), the opposite is true and there is an immediate CONTRIBUTION TO PROFIT.

Regulators, investment bankers, attorneys, even the SEC should stop a moment and think about this. If the insurance company has a vested interest in “under reserving” what claims practices could be put into place that would appear credible yet keep total financial reserves at a minimum, or actually produce contributions to profit at certain periods of the year i.e. quarter or year-end profits?

Unfortunately, neither federal nor state regulators know enough about the internal claims review processes of most insurers to identify strategic practices intended to reduce financial reserves when profits are needed. Regulators need to take a better look at the realistic claim reserve figures and determine what internal claims practices are routinely put in place to keep financial reserves at a minimum, potentially under amounts required by federal and state regulators.

Generally, nearly all U.S. disability insurers can understate financial reserves by integrating their benefit pay system with the company’s overall financial claim reserve figures. The financial reserve figure associated with each claim goes up when the claim is approved, and profits are made when the reserve is reduced or eliminated as in the case of a claim denial. Other offsets such as SSDI, and Worker’s Compensation, and reducing benefit payments to $0 also positively affect financial reserve.

Each disability insurer maintains an electronic “benefit payment system” from which benefits are paid and offsets recorded. Therefore, each insurer can manipulate the amount of financial reserves simply by coding offsets such as primary and family social security, retirement income, worker’s comp etc. Interestingly, certain insurers can also “create” special pay status’ such as reservation of rights and SSDI presumptive that, when coded, will also reduce claims reserves and contribute to profit at any time.

Therefore, if an insurer integrates the following with their internal benefit pay system; financial reserves can be seriously under-reserved:

  • Coding of Reservation of Rights status.
  • Coding of SSDI presumptive such as blindness, end stage renal disease, loss of limbs etc.
  • Coding of estimates for primary and family SSDI. 4. Coding of other expected offsets to benefits prior to realization.
  • Coding of actual SSDI award amounts.
  • Deliberate omissions of contract payment obligations such as revenue income protection provisions, payment of COLA and SSDI Supplemental benefits.
  • Coding of Advance Pay & Close.

Disability insurance management is very clever. Unfortunately, deliberate attempts at under reserving literally “pulls the wool over” regulator and brokerage houses’ eyes since the company is not as financially sound as reported to these entities. Making matters worse, some states allow the insurance company to recover amounts paid to the insured while on ROR status if it is later determined the company does not have liability for the claim. Presently, most insurers agree only to pursue monetary recovery only in cases of fraud. To do otherwise would be to draw attention to the strategy of “under-reserving” since recovering the benefits would certainly cause financial hardship and complaints to regulators.

For disability claims, Reservation of Rights status is defined as a pay status whereby an insured is notified in writing the disability insurer may not have liability to pay the claim in the future. ROR notification actually allows companies like Unum Group to investigate a claim to determine if it has liability to pay the claim without waiving its right to later deny coverage based on information obtained as a result of the investigation.

Although ROR status protects the interests of the insurer, it should be regarded as an alert to the claimant that some fact or element of the claim has been brought into question which could be used at a later time to deny the claim.

But, that’s not the entire story. Once a claim has been coded on the benefit payment system as “paid under reservation of rights”, the system automatically adjusts the financial claim reserve downward (referred to as a financial reserve gain) producing an immediate contribution to profit. This is why a large percentage of claimants are notified of ROR status just prior to year-end – 2017 was no exception. This would suggest that something “changed” in the claim challenging the future payment of benefits.

Not so. Claimants are placed on ROR status for no other reason than the say-so of a manager or consultant who simply says, “I think we can deny this claim in the future.” Theoretically, insurance companies have an obligation to produce actual claim documentation (or lack of it) proving it is likely the company will not have liability to pay the claim in the future. This is why DCS, Inc. challenges the assignment of ROR status by asking the company to produce file documentation or specific cause for ROR status. In the absence of documentation challenging future liability for the claim, the assignment of ROR status has no other value than to reduce the financial reserve causing an immediate realization of profit to the company.

For example, here are some of the inappropriate reasons Unum Group places claimants on ROR status:

Any occupation investigation. Regulators should really pay attention to this. Unum begins “any occupation” investigations between 9-18 months of paid benefits. Updated medical information needs to be obtained and reviewed, vocational reports should be completed, and “gainful” needs to be documented. There is absolutely no proof 9-18 months before the results of the “any occupation” investigation is completed, that Unum will NOT have future liability for the claim.

However, if Unum codes a “ROR” status on the pay system for the claim, it receives a premature “contribution to profit” when the outcome of the investigation has not even been received! In a sense, to record ROR status before receiving a TSA (Transferable Skills Analysis) identifying alternative occupations, is actually pre-determining the outcome of a claim, or put another way, targeting a claim for the certainty of denial. Unum receives approximately 450,000+ group claims per year. Consider the lowering impact of Reservation of Rights status. If all of the claims were to be placed on ROR status between 9-18 months, can you guess how under reserved the company is?

Our medical opinion doesn’t agree with your medical opinion. I think we can all agree insurance companies generally buy physicians who “rubber stamp” denial decisions. Insurance physicians who have been in the business for a while learn the lingo of claim denial very quickly. Of course, it is very easy and convenient to deny disability claims when the only opinions considered are its own. If the medical opinions of Unum’s physicians differ from that of the primary care physicians, a manager may place the claim on ROR status particularly at the end of a quarter or year. This was the case for 2016.

 Any manager say-so. Managers and Directors have a great deal of responsibility to “roll out” certain levels of profit for the corporation. This is what they get the big monetary incentives for. Since the multistate settlement agreement Unum has no doubt “bumped up” reserve accountability to senior management such as vice presidents and other top executive personnel. Claims handlers are kept dumb on the issue of financial reserve.

However, managers ARE aware of claims reserves and how the denial of claims produces profit. A manager would have to be the dullest knife in the drawer not to know how to manipulate reserves in order to meet company financial goals. This is what most managers actually do.

Insufficient “objective” medical evidence to support payment. Of course, the insurance company is the entity who decides what is “sufficient evidence” to support a claim (discretionary authority), which is having the fox in charge of the hen-house so to speak. The insurance company can, at any time, arbitrarily decide there is NEVER enough evidence to support a payable claim.

Reservation of Rights status is supposed to be a relatively short-lived pay status, however, getting a disability insurer to remove the ROR status after having benefitted from it by reducing the financial reserve, is very difficult since claims reserves increase again (reserve loss) reducing profit once the status is removed.

Therefore, most disability insurers will delay removing the ROR status, or at best, procrastinate removing it to avoid the inevitable reserve loss. Bottom line, if a claimant receives a letter from their disability insurer informing a pay status of Reservation of Rights, please note the following:

  • It means the insurance company is notifying you it has begun an investigation of your claim because they either do not have sufficient proof of claim, or there is evidence to suggest the company will NOT have liability for your claim in the future.
  • The insurance company is nearing the end of a quarter (March, June, and September) or year-end (December) and needs to reduce the amount of financial reserves to show targeted or expected profits.
  • If the insurance company has not told you in writing it will only attempt to recover amounts paid for cases of fraud, it can attempt to recover any monies it has paid you as of the date of the letter. (Actually, paid benefits from the date of ROR notification to the date of the denial letter.)
  • The insurance company made a profit from your claim even though it actually paid you while the investigation was going on.
  • The insurance company may have pre-determined to deny your claim at a later date.
  • If the investigation is favorable to the insured and the claim is approved and paid, the insurance company understated its liability for the claim for the period of time it took to obtain what it felt was lacking. This is actually referred to as “Off-Balance Sheet Financing.”
  • ROR status for “any occupation investigations” presumes (incorrectly) what the outcome of the Transferable Skills Analysis will be for longer periods of times perhaps as long as 18 months. If it was later determined the insured met the definition of disability after 24 months, then the claim was under-reserved for as long as 18 months, assuming the company removed the status promptly, which may or may not happen.

Regulators should exercise more oversight into the manipulation of financial claim reserves by using the actual claims process and pay system to adjust claim reserves. It is very likely the indiscriminate use of ROR pay status by disability insurers could cause disability insurers to be under-reserved to the point of not being able to cover future claims.

Remember, Reservation of Rights is only one of several ways in which disability insurers manipulate financial reserves.  Using UnumProvident as an example, prior to June of 1999 it was alleged Provident’s management integrated Expected Recovery Dates (ERDs) with Unum’s benefit payment system (BAS) to reduce and increase financial reserves based on “anticipated”( informed guesses) recovery dates.

We know ERDs were coded into BAS (Benefit Administration System) and these “expected recovery dates” could not be changed without manager approval. ERDs were initially determined by RNs and other medical staff, but once it became apparent financial reserves could easily be manipulated via the ERDs, consultants and managers also determined expected recovery dates by review even though they were not medically trained to do so.

It is also alleged the more conservative financial reserve achieved prior to June of 1999 may have contributed to the attractiveness of the merger between Unum Life Insurance Company and the Provident Companies. Integrating varying expected dates of recovery to ERDs did NOT work and caused several problems: “Expected dates of recovery” are not certain. Human beings do NOT recover by planned, textbook definition of impairments, symptoms and recovery.

Furthermore, UnumProvident tried to use an online MDA (Medical Dictionary of Recovery), but still claimants blew the established ERDs into the water causing frequent fluctuations in financial reserves as ERDs had to be changed. Income and profit reporting was not consistent. As a result, ERDs caused Unum to be grossly under-reserved.

Subsequent to the Multi-State Settlement Agreement and introspection of regulators at the time, Unum subsequently contributed to its reserve figures to bring it more in line with regulation and investment requirements. Since the ERD experiment failed miserably, sometime in 2001, it is believed Unum disconnected ERDs from financial reserves and allowed senior claims handlers to make adjustments to the dates of recovery. Eventually, ERDs were done away with, or at least in the context they were previously used.

Clearly, federal and state regulators looked only at the big picture, or macro view, of financial reserve compliance. If Unum, for example, reports $X dollars for financial reserves and the figure is within the required limit, very little inspection is given to the company’s internal processes to determine how deductions in reserves are actually accomplished and whether the reserve amounts actually equate with realized liability.

In other words, the bottom line isn’t always the bottom line. This consultant has been recommending to federal and state regulators since 2002 that a more micro inspection of actual claims processes and pay system integrations with offsets and reserve deductions be undertaken to reconcile actual liability for claims with financial reserve figures.It is likely further investigation may discover all disability insurers are under-reserved.

From an accounting and investment perspective, recording under-valued liabilities (financial reserves) is actually engaging in “off-balance sheet financing” since the true liability for future claims does not appear on the statement. Those investment brokerages who public bond ratings etc. should take particular interest in whether or not financial claim reserves are under reported on the financial statements. Audits are performed; but the problem is in not comparing the full realized value of what financial claim reserves “should be” vs. “what they are”, and not investigating the extent to which disability insurers manipulate reserves by integrating reserve gains (and losses) with the benefit payment system and strategic processes deliberately put in place to indiscriminately place claims on ROR status.

As long as comparisons are not made by regulators and auditors between reported financial reserves and the ability to manipulate reserves by engaging in “off-balance sheet financing” via the benefit payment system, disability insurers will continue to grossly under-reserve future liability of claims and report profits which are largely Aesop’s Fables.

If anyone has any questions concerning Reservation of Rights status and what it means to you as an insured, please contact me by email at: DCS@metrocast.net.

Pain. Although most of us endure the occasional aches and pains of tension headaches, bumps, thumps, bruises, strains and sprains, there are many others who suffer daily chronic pain from many different sources which cannot be lessened with over-the-counter remedies such as Tylenol or Advil.

What is felt as excruciating pain by one person can be experienced as a headache by another. Pain derives from many sources within the body and is generally exacerbated by anxiety, stress and depression. For many receiving disability benefits there is no end in sight to pain that is relentless, and chronically severe.

Many of these individuals eventually file disability claims only to become misunderstood and accused of malingering. Since pain is an unseen or immeasurable result of physical “brokenness” within the body, it is considered by disability insurers to be “subjective” and “self-reported.” In many instances, those who suffer with chronic pain are often accused of experiencing pain only as a “somaticized” symptom (imaginary) derived from an unidentified mental disease.

Therefore, in their haste to relieve themselves of liability for chronic pain claims, most disability insurers opt for the opinion that “if it cannot be measured, we cannot pay.” Most US disability insurers now have the attitude that since “pain” cannot be objectified, it is deliberately exaggerated by most insureds in order to receive secondary gain by not working.

To further complicate the issues of pain is the fact that each individual has their own threshold of endurance. It’s clear that while some employees  experiencing chronic pain are able to continue working, many others cannot sustain productive work. It has always been my experience that most employees will continue working for financial purposes until the pain reaches higher levels on the pain scale and they can no longer endure it.

Disability insurers generally do not attempt to distinguish between thresholds of pain, which is a major flaw in the disability claims review process. Once insurers accept the notion that pain is “self-reported”, it is very easy to build internal protocols based on the companies’ own self-interests to allege claims are non-compensable.

What disability insurers often forget (deliberately) is that pain hurts, and long-term pain becomes impairment when insureds are no longer able to manage severe uncomfortableness while sustaining full-time work. After all, pain requires an individual’s full attention, which is not conducive to performing tasks well on-the-job.

Human beings are physically made to withstand moderate levels of pain for short periods of time. Women can endure the pains of childbirth because they know the pain won’t last forever. Although a broken leg is extremely painful, it can be fixed and the pain alleviated. Pain, even at its most severe levels can be endured for short periods of time.

However, chronic or predictable pain such as in migraine headaches, is long-lasting with no expected light at the end of the tunnel. Individuals who have chronic pain on a daily basis eventually become exhausted, worn down, and depressed at the idea of having perpetual pain, sometimes for the rest of their lives. Some insureds are not believed by members of their familial support groups and can be considered “slackers”, or “Aunt Martha just doesn’t want to work anyway.” It can be very frustrating for insureds suffering from pain when they aren’t believed by those who may have to provide  comfort and care.

What constitutes credible impairment for disability is not only the existence of chronic pain, but also the after effects of longstanding daily management of chronic pain. The longer insureds endure pain at their own threshold level, the more “impaired the individual becomes for disability purposes.”

With the tendency of physicians to over prescribe opiates, many of those diagnosed with pain become addicted and dependent on medication management to simply get through the day. Although “cocktails” of Fentanyl and Oxycontin are very dangerous medications, physicians often prescribe them together and hope for the best.

The insureds’ actual claimed primary disabilities then become fatigue, depression, exhaustion, and despair caused by secondary or breakthrough pain. Many insureds find it helpful to seek out counseling or pain management as an aid to managing levels of pain that interferes with everyday life.

One of the most encouraging, non-opiate medication for chronic pain is medicinal marijuana. Although the pain is still present, patients taking marijuana report they no longer care it’s there, and can drastically reduce or eliminate opiate medications entirely.

Pain hurts, and those who suffer pain for extended periods of time can occasionally lose their threshold of tolerance and have a meltdown described as “a total loss of one’s ability to endure ANY level of pain in combination with a release of emotion as a result of enduring high levels of pain for long periods of time.” This is a pain “meltdown.”

Recently, one of my clients described himself in the Emergency Room in tears because his migraine medication wasn’t working. Once insureds begin to experience a pain meltdown they will usually go anywhere, do anything they can, to make the pain go away, including buying street drugs.

Another client developed a habit of hurting herself (falling off a bicycle and down stairs) so that she could be taken to the ER in hopes of obtaining even more pain medication. Fortunately, ER physicians are reluctant to over prescribe pain medications and will only give 1 dose and advise patients to contact their own physicians as soon as possible.

Disability insurers need to reconsider and change their protocols and perspectives toward paying chronic pain claims by looking beyond the “subjective” caption to other symptoms caused by pain. If an insured is diagnosed with depression because she cries everyday due to pain, then it is reasonable to say her primary diagnosis is chronic pain, not depression.

Insureds who have chronic pain, regardless of the source, should always mark their levels of pain on a visual analog scale and keep a pain journal. Other symptoms resulting from pain such as fatigue, exhaustion, loss of temper, irritation, inability to think clearly or concentrate, should be clearly documented in the journal and shown to treating physicians.

Over the last 25 years of claims management I’ve developed an expertise in helping insureds manage chronic pain disability claims. In most instances chronic pain is experienced by those suffering from “failed back surgery syndrome” and connective tissue disease such as FMS.

And remember, it’s OK to have a meltdown in the ER once in a while. The longer a person endures and attempts to manage pain, the more impaired he/she becomes for disability purposes, and the lower tolerances will be.

Those of us who give in to an occasional Advil cannot imagine the pain levels some people have to endure, often for the rest of their lives. It’s time disability insurers change their archaic views regarding pain and place credibility on the totality of dysfunction caused by chronic pain rather than classifying pain as “self-reported” in order to avoid payment.

There’s no question but that claims for pain need to be managed well in order to receive benefits.

 

As a former Lead Benefit Specialist with both Unum Life and UnumProvident I’ve seen thousands of communications from claimants from every major US disability insurer. During those conversations I have been called quite a few names – some good, and some very bad. Learning what to say and not say to insurers who are looking to deny claims is a learning process and takes time.

Here are a few “tips” if you are managing your claim on your own. DCS, Inc.’s clients are not recommended to speak with any insurer on the phone, but if you take the risk and do it anyway, please pay attention.

Be brief. Anytime a claim is filed with a disability insurer, the claims handlers will attempt to interview you by phone. Unum, for example, is required to contact you for such an interview within 3-5 days of assigning your claim to a claims examiner. There is a template list of questions approved by management, and all claims handlers are trained to plan the communication in such a way to encourage you to provide information about yourself and your family.

In today’s technological terms, family member names and other information are like “gold” to insurance companies. From the data provided by you they are able to locate family Facebook sites and obtain additional information about your activities. I do not recommend participation in any social media if you are receiving disability claim benefits.

You will also be asked “What happened?” “Name your treating physicians.” “What are your prescribed medications?” “What other income do you have?” “Have you applied for SSDI, Worker’s Comp etc.?” And so on. Of course, insureds should always answer questions honestly but do not elaborate. Don’t offer any explanations beyond what is being asked. Answer only what is asked and stop. I know that’s extremely hard, since your first instinct is to want the claims examiner to believe you. Remember, the claims examiner’s agenda is to close your claim if they can. Toward that end, everything you say can be used against you. Answer only the questions asked, then stop talking. Remember, DCS, Inc. does not recommend speaking with any insurance company on the phone.

Resist the temptation to tell the story of your life. I am reminded of one scenario in particular that happened so often in the Unum claims department.

The claims handler calls the insured for the initial interview and the claimant begins to speak in what seems like an endless story of his/her life. In that conversation, he says “It’s going to be hard for me because my wife was just diagnosed with leukemia.” Well, its likely Unum will say you filed a disability claim because you want to take care of your wife. Anything not directly related to your impairment should not be discussed with your insurer. Remember, an insurance company cannot hold against you what you do not say.

Here’s another example, “ My wife is working, so I’m taking care of my kids.” Or “ I’m taking care of my grandchildren.” I cannot stress enough how often that kind of information is held against insureds.  In addition, DO NOT WRITE LONG LETTERS TO Unum or any other disability insurer. The assumption is, if you can type or write long 10-15 page letters, you can work. Resist the temptation to send any communication more than 1 page to Unum. You are not obligated to tell the insurance company anything that is not directly related to your insurance policy and your impairment. No family information should be given and nothing not addressed in your policy should be discussed.

ABC – “Always Be Cool. As I mentioned in the intro to this article, I have been called everything although my favorite was “Attila the Hun.” I’ve listened to profanity, anger, tears, frustration, threats, desperation, phone slams, you name it, and if you can think it, I’ve probably been called it. The truth is, though, the claims handler knows something you don’t. When you lose your cool, Unum’s in control and you aren’t. Please don’t ever let an insurance company control you or your claim.

Since everything is documented, anything you say, and the manner in which you say it, will be held against you. Disability insurance companies are not concerned with what you say, or, call them. They just want your claim to go away.

Insurers generally are only concerned in using what you say as a reason to peg you as a “nut” and support your claim for denial. Whenever you feel like calling the claims examiner names, or telling Unum to “stuff it,” go into a closet let it all out, then write a short, polite letter discussing only the facts of your claim, limited to one page, making sure to keep a copy. You are talking to an insurance company who does not care what you call them; they don’t care what you think; and, clearly they don’t care if you get paid or not.

Never download medical information from the Internet and send it in. Why not? Unum doesn’t care. They won’t read it. It may get pitched. It will be used against you. If Unum has made a decision to disregard the opinions of your primary care physician, why would they care about medical information YOU downloaded from the Internet about your impairment? Technically, if you send it in, it is supposed to be a part of the Administrative Record (your claim file). I had an attorney from Unum’s legal department tell me once “All this downloaded information means is that the claimant’s attorney knows how to use the Internet and save PDF documents.”

Unum is scanning and imaging all paper now in Chattanooga, so it would be interesting to see just how much of  downloaded “stuff” from the Internet is actually scanned on the permanent record. (Image) When it was an “all paper claim” most of this information “hit the can.” If your occupation was as a Secretary, for example, sitting at a computer, downloading, and printing a lot of paperwork to send to Unum could be interpreted as work capacity. Don’t bother, no insurance company cares how much you can download from the Internet.

Maintain a journal. Getting angry will not serve you well when dealing with any disability insurer. Make sure you start a journal or diary and keep records of all conversations you have with Unum or any other company. Ask for names of Consultants, Managers, Directors, Vocational and Medical reviewers and document the substance of every conversation and call you have and receive from your disability insurer. Sometimes the claims examiners are not professional with you, so make sure you document those conversations as well.

Document, document, document. DCS, Inc. uses Evernote to document all activities on client claims. You should do the same if you are managing your disability claim alone.


I know it is difficult enough trying to get a disability claim paid these days. It’s a frustrating process. But, name calling, accusations, anger and profanity just come back to haunt you in the end. Some insurers even questions whether or not insureds should be in counseling because of the way they behave when speaking with the insurance company.

Engaging in such conversation gives the insurance company control over you and your claim. Don’t give them that kind of power. DCS, Inc. clients have a much easier road in this regard since they have the expert help needed to navigate the system safely.

 

First there is a request for your SSDI Award Letter. Then a letter arrives from Lucens asking you to sign an Authorization releasing financial SSA information. Next, a letter arrives requesting all SSA 1099’s relating to SSDI payments. Finally, a letter arrives informing you that you owe Unum an excessive amount in overpayment since Unum overpaid you. Whenever is it going to end?

Do you get the impression Unum is fishing for something? In my opinion, the company’s targeting of SSDI (including all of the ERISA folks), and past and present IDI “Residual” insureds to recalculate SSDI offsets and earnings is for the purpose of, well let’s say, “creative accounting” to arrive at large overpayments due. Every time Unum’s management fixates on a new financial target, they keep coming up with different answers that costs claimants and insureds money.

The ultimate goal of such internal projects is to reduce claimant benefits to $0 (increasing cash flow) until the alleged overpayments are paid back. Although Unum is well-known for its fictitious overpayments resulting from recalculations, Unum’s new initiative involving a new outsourced company, Lucens, appears to be targeting every one to “verify” SSDI, other offsets, and residual earnings.

With respect to SSDI offset calculations, SSA’s initial approval letter contains all of the information needed for Unum to calculate an accurate offset and overpayment amount. Requesting SSA 1099’s will not be helpful to Unum in this regard since only the total amount of benefit received is recorded on the 1099 and the amount of COLA increase is not broken out.

Of course, Unum’s ERISA Plans do not offset for COLA so the 1099’s won’t be helpful. Why  provide documentation to Unum (or Lucens) that Unum will misrepresent as total benefits (offsets) when it includes COLA amounts? The only figure Unum is permitted to offset is the amount of the original award. This figure is always on the initial award letter SSA sends out to those with approved benefits.

There are so many SSDI complicated situations I couldn’t begin to explain them here, but I am reminded of cases where a disabled father’s children are awarded dependent coverage that goes to the mother, the (custodial spouse). The claimant is already getting hit twice and doesn’t need Unum to allege he owes back more money when he doesn’t.

I don’t think anyone would challenge Unum’s overpayment recalculation due to error within a reasonable amount of time – this makes sense, correct the error and move on. But, when hundreds of people, having been on claim for many years begin receiving letters from Unum alleging large overpayments, this is an indication of a “pattern of practice”, or initiative to demand repayment of overpayments that are merely the result of recalculation to deliberately generate cash flow. It’s insurance fraud, and it needs to be addressed legally.

In my opinion, Unum Group is not to be trusted in any manner when dealing with disability claims, including any other review process related to indemnity products. As I described in prior posts, inside information indicates the company is silently doing away with many of its departments while cloaking the fact they no longer exist. How can you trust a company like that?

Employees are also terminated as the company outsources work to companies like Lucens, also partners in recalculating financial information to meet Unum’s goals and objectives. It’s unfortunate, but in my opinion Lucens, as a company, will eventually inherit Unum’s very poor public reputation as collaborators in Unum’s schemes. When you take on the world’s worst disability insurance company as a client, there is a certainty of future negative goodwill.

In any event, Unum is requesting financial information for the purpose of recalculating offsets and overpayments for the purpose of collecting huge overpayments by reducing benefits to $0.

If this is happening to you please send me an email; I may have more information to provide at a later time.


And, by the way, those claimants who have opted for estimated SSDI deductions from benefits may also be at risk. There have been a few reported cases that Unum deducted estimates for SSDI from benefits, denied claims, and won’t give the money back even if claimants weren’t awarded SSDI at the time of the denial.

General consensus from several reputable sources indicates it’s better to have Unum chasing you for recovery of overpayment than the other way around. While DCS, Inc. supports timely repayment of what is owed, it’s no longer a good idea to opt for estimated deductions for SSDI.