Claim file evidence indicates Unum Group has been operating in violation of the Multi-State Settlement Agreement and Regulatory Settlement Amendments in the following ways:
Excessive reliance on in-house medical staff to support the denial, termination,or reduction of benefits;
Unfair evaluation and interpretation of attending physician or independent medical examiner reports;
Failure to evaluate the totality of the claimant’s medical condition; and
An inappropriate burden placed on claimants to justify eligibility for benefits.
In addition, Unum also violates the Regulatory Settlement Amendment Section B.3 c (i) 5 which states:
“…shall be amended by adding the following factor to others relating to increased focus on policies relating to medical evidence: Giving significant weight to an attending physician’s (“AP”) opinion, if the AP is properly licensed and the claimed medical condition falls within the AP’s customary area of practice, unless the AP’s opinion is not well supported by medically acceptable clinical or diagnostic standards and is inconsistent with other substantial evidence in the record. In order for an AP’s opinion to be rejected, the claim file must include specific reasons why the opinion is not well supported by medically acceptable clinical or diagnostic standards and is inconsistent with other substantial evidence in the record.”
Unum celebrated the end of the Multi-State Settlement Agreement in late 2008 with cake and cookies, reorganized into Unum Group and went back to its old unfair claims practice of ignoring all medical opinions rendered by insureds’ treating physicians.
Denial letters forwarded to DCS indicate Unum makes doc-to-doc calls and then documents it still disagrees with the medical restrictions provided by the claimant’s doc. What’s the point? It’s too easy to deny and terminate disability claims when the only opinions considered are those of the payer. These procedures are definitive “conflicts of interest” since Unum is both “reviewer” and “payer” of claims.
Unum continues to engage in unfair claims practices especially now when regulators aren’t watching. To my knowledge there have been several complaints made to the Maine Department of Insurance (one of the three lead-regulators involved with the multi-state) and nothing has been done to investigate Unum Group’s current claims practices or determine whether or not the company should pay the additional fines for continued violations of its agreements. Complaints to the Maine DOI have been “handed off” to a law firm in Boston known to have been influenced by Unum during the Multi-State claim investigations.
In the meantime, while regulators are reluctant to investigate the company by immediately engaging in conduct market evaluations, hundreds of claimants and insureds are being harmed by unfair and egregious claims practices while Unum’s stock continues to increase. What a shame!