Unum’s most popular current strategy to deny more claims is to completely ignore any medical opinions provided by the insured’s primary care physicians. Although the company meticulously chases after updated Attending Physician Statements and current patient records, these documents are referred for internal review to physicians who are paid financial incentives to agree with, and support, the company’s internal claims strategies. Several years ago Unum’s physicians participated in the Management Incentive Compensation Program (MICP) which offered Unum’s management (including physicians and nurses) yearly bonuses equal to 30% of yearly salary. Although it is currently unclear whether Unum continues to offer the MICP program, it is unlikely physician insurance consultants are willing to work without some type of similar financial incentive.
As a result of the Multi-State Conduct Market Evaluations, Unum was found to have engaged in unfair claims practices by not placing any weight on the opinions of primary care physicians. Although in 2004 UnumProvident was required to change this egregious claims practice, it appears Unum has since gone back to its old strategies after the RSA when the claims reassessment was declared a done deal in 2008. This is very unfortunate for Unum insureds and claimants since it means Unum’s insurance-paid physicians can document opinions which in some cases are medically unsound and the company can actually get away with it.
For example, in denying an ERISA claim for a claimant diagnosed with HIV/AIDS Unum claimed the individual was able to fully return to an executive-type position with a T-cell count greater than 200. In researching the T-cell marker of 200, DCS was unable to find any medical literature declaring a T-cell count of 200 as an indicator of health sufficient to enable a patient to return to work on a consistent or sustainable basis. Medical evidence found did indicate a T-cell count of 200 or less was regarded by physicians as markers of potentially dangerous bacterial infections commonly known to infect HIV/AIDS patients. In fact, the medical research DCS found stated the marker for a HIV/AIDS patient indicative of “good health” was a T-cell count of 500.
Unum’s rationale for using a T-cell count of 200 to allege the ability to return to work, with full-duty is to say the least, ridiculous because if presumes although an HIV patient with a T-cell count of 200 may not have a serious bacterial infection, he/she is healthy enough to work. Unum’s docs conveniently leave out the part that persons with T-cell counts slightly above 200 are still sick and probably have other symptoms which preclude work. What is Unum trying to sell people these days?
Unum Group is very clever in constructing facts and opinions that appear credible, but in fact are nothing more than Aesop’s Fables. Recently, one of Unum’s internal physicians wrote to an eminently qualified infectious disease doc asking the question, “Can you please explain why you are supporting disability and treatment not approved by the FDA?” This particular claim had been denied for a claimant diagnosed with toxic mold encephalopathy and chemical sensitivity.
First of all, policy contracts do not require medical diagnoses and treatments approved by the FDA. I have never seen a disability contract with provisions that specifically require FDA approval of medical restrictions and limitations precluding work. Nearly all disability policy contracts require the insured to be unable to perform the material and substantial duties of their own or any other occupation and be in treatment with a qualified physician. Depending on your views of the FDA we can all be thankful the payment of disability claims does not require FDA approval otherwise claimants might be waiting for a very long time to get their first check. Unum’s medical staff already uses the CDC and MDA as cited sources for denying claims, and now adds the FDA to its list?
One has to wonder to what lengths Unum Group will go to discredit any cause of medical disability in an effort to profit by increased claim terminations. Additionally, one has to also ask questions about the caliber of insurance-paid physicians who “make up” and exaggerate medical facts in order to allege insureds can return to work.
A recent hearing before the Senate Finance Committee also mentioned the large groups of IME and peer physicians, who for money and personal gain, abuse their medical credentials as employees of egregious insurance companies. What does it take for a licensed medical doctor to misstate facts as an employee of an insurance company? Money, money, and more money!
In any case, Unum’s medical department appears to be out of control in documenting medical statements which are not supported by facts generally accepted either with objective evidence or standard history and clinical treatment of the primary care physician.
In addition, letters being sent outside of the organization by Unum physicians are administrative and secretarial nightmares. Filled with spelling and format errors, Unum’s physician letters often appear to have been written by a high school student. (No offense to high school students.) Fonts and paragraphs are often skewed, bullets are mis-formatted, and sentence and idea construction often does not make sense. There was a time when Unum took pride in its written communication, but apparently that is no longer true.
The scary aspect of Unum’s physician statements is that no one challenges the validity of the questions except for primary care physicians who simply say, “that’s not true at all.” Unum says it is……everyone else says it’s not.
Beware of Unum’s frivolous medical statements supporting work ability. Chances are the statements are not medically sound; support Unum’s internal strategies to deny more claims; and are bought and paid for with yearly financial incentives. Unum goes out of its way to purchase the medical credentials of its physicians who “rubber stamp” denials and often demands the physicians “pay up” when additional terminations are needed.
In the future, mercenary physicians who work to assist disability insurers with their strategies to deny claims may find themselves accountable to their medical boards. After all, insurance physicians are medical doctors first, and employees of the insurance company second. Shouldn’t they be held to the highest standard of ethical conduct?
And, by the way….I’m not sure I’d trust a physician who can’t write a legible letter free of errors.