Years ago Unum’s claims training manuals contained the following instruction, “If it isn’t documented in the file, it didn’t happen.” In theory at least, any person should be able to pick up or access a disability claim file and be able to follow a chronological sequence of activity and/or actions that occurred in the review process. Claims handlers were told to document everything until it became evident “excess claim documentation” was getting insurers into trouble with regulators.
In the past, Unum claims handlers took “documentation” to the extreme and wrote derogatory comments about claimants into the record. “This claimant is a liar!”, one piece of documentation recorded, while other files contained comments such as, “This claimant doesn’t have fibromyalgia, she’s just lazy”, and “He’s never home, and probably a crazy nut.” Personal comments citing claims handler’s opinions are never appropriate documentation and Unum quickly found out regulators and plaintiff’s attorneys held the company accountable for unprofessional file writings. The company quickly changed its point of view from “document everything” to “document next to nothing.”
Although historically all file documentation was handwritten in paper files, today insurers use some sort of electronic diary software to keep track of activities and actions taking place in the claims review process. Some insurers use SOAP Notes, an acronym for “subjective, objective, assessment and plan” which is a mouthful to say the least. Claims handlers are responsible for making notations into the program for each file making sure a chronological record is generated. Unum uses Navalink, another electronic diary program.
File diary records are “discoverable” meaning they must be disclosed at the time of ERISA denials, or can be subpoenaed by DI attorneys in litigation. Clearly, in an effort to “hide” parts of their internal claims process, it was common to “sanitize” the claim file by removing documentation insurers didn’t want “outsiders” to know. At the time of the multistate settlement Unum’s managers were “sanitizing” claim documentation at will. Unum was forced to stop removing documentation from claim files, but quickly adopted strategies to minimize file documentation instead of “writing down everything that happened.” Hence at Unum, Genesis was replaced with Navalink, which significantly reduces the amount of actual file documentation.
Of importance to insureds and claimants is that claims handlers are trained to selectively document the meaning of what is said, rather than what is actually said. This is why DCS, Inc. will continue to recommend “no phone contact and all communication is writing” so that there can be no question as to what was communicated. Claims handlers, like all employees, cover their backsides with, “I never said that”, or “you misinterpreted what I said.” At times, claimants can be made to look wrong and foolish by claims handlers covering up their claims mistakes. (And by the way, claimants should never communicate with treating physicians by email since the emails become part of patient files which insurers have access to.)
Of course the newest aspect of document communication is by email which again is a very bad idea. Claimants can never be sure emails are added to the official record. Online insurance websites may or may not be kept up to date and should never be claimants’ primary sources of information about their claims. Claimants have a tendency, like social networking, to OVERSPEAK information when using emails – a fact I’m sure insurers are well aware of.
Claimants should consider the issue of claim file documentation seriously. Since insurers are not required to “disclose” internal file documentation until claims are denied, it becomes very important for insureds to make sure their point of view, and the opinions of treating physicians are also in the record making written, not verbal communication even more necessary. Allowing any disability insurer to have a documented consensus about anything is a mistake.
Remember, claims handler’s aren’t documenting what you actually say, but rather what they think you said means. Therefore, it is important to “set the record straight” when inconsistencies become known. Clearly, if insurers are no longer permitted to “take out of the official record”, they certainly aren’t going to “document it in the first place.” The tendency today is for insurers to minimize descriptions of claim activity rather than generating a complete chronological record.
After all there is an advantage to insurers in hiding parts of the claims review process such as round table proceedings, and IME documentation between the IME Network and physicians hired to perform evaluations. Those claimants who obtained copies of their files after claim denials often tell us information is “missing.” Either someone in the company deliberately removed the information, or the insurers’ mail centers are completely inadequate and ineffecient. “Missing paperwork” happens way too often to really be the result of disorganization and negligence all the time.
Today, the real claims process isn’t documented anywhere, and there is no real accurate chronological record of claim file activity. Although diary programs such as SOAP Notes and Navalink appear to document what’s entered adequately, it’s what’s NOT documented we should be more concerned about.
Claimants should think twice about communicating with insurers on the phone since one is never sure what’s written down on the other end. Also, inaccuracies should always be corrected “for the record.”
