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Archive for the ‘Bad Faith’ Category

In the past, I supported Mass Mutual as a fair reviewer. In fact, it was commonly known that “Mutual” insurers tend to offer fair claims reviews since insureds are actually owners of the company and are treated fairly when they file claims.

However, over the last several years Mass Mutual descended into the abyss of egregious claim reviewers when the company showed signs of untimely review, interpretations of policy provisions unfavorable to insureds, poor customer service, and use of third-party biased medical reviewers to support terminations.

One such case in point is an elderly executive with a history of mental illness including several incidents of attempted suicide requiring brief in-patient care. Although his history is fairly complicated, he eventually was forced to sell his companies and file for disability because of his chronic pain and inability to manage his depression and anxiety.  The policy with Mass Mutual is for Lifetime and has no limitation for mental and nervous disease. The claim is also worth approximately 2.5M in financial reserve.

Mr. X. was able to manage his life, but just. With he help of his wife, he appeared to be managing his symptoms of chronic pain without the opiates that got him in trouble. After a physician prescribed medicinal marijuana, Mr. X. was able to continue counseling and was living his life with disability benefits until he got word Mass Mutual was demanding an IME.

On the day of the IME, a neuropsychological evaluation, Mr. X. was asked to complete questionnaires in a reception waiting room. The IME physician and his staff could only be described as “smart alecks” who took pot shots at the insured and moved him around from room to room for the test taking. To make a long story short, Mr. X. had to return for another session, and the IME was documented that he could return to work.

Those who have been diagnosed with mental health issues serious enough to stop them from working are generally managing life on the edge. The complex process of living with a disability claim in combination with the inability to manage basic life situations often deprives insureds of basic life skills needed in order to be successful.

Clearly, trying to manage through an unfair claims process that includes meeting deadlines, preparing multi-page updates, and submitting to external reviews, can seriously impair one’s ability to think and act in a way that produces successful claims.

I’ve had several recent dealings with Mass Mutual involving contract interpretation that is largely an Aesop’s Fable concocted to support not paying benefits in accordance with policy provisions. I’ve also been in contact with claims handlers that seem a bit spaced and not well-trained in the area of disability claims.

While Mass Mutual used to be considered a good company, there are evidences that it has now fallen into the devil’s den of unfair claims review. In addition, Mass Mutual is not the only company to slip into the abyss. In fact, it now joins Guardian/Berkshire as notable has beens in the fair review category.

Those with Mass Mutual claims need to be particularly wary of policy citations that are not contractual, and the use of third-party reviewers, including IMEs that are really arms of an insurance industry lending denial support.

Mr. X.’s claim in particular showed at least a $2.5M hit to profitability when it was denied. The decision to deny Mr. X.’s claim at his expense was a really bad one, probably one of many resulting from the new Mass Mutual mantra of denying claims unfairly.

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One of the companies I’ve been watching for several years is The Standard – a misnamed organization that has no standards when it comes to administering Disability Claims. By my observation alone, and in conjunction with working for attorneys filing appeals, it is obvious The Standard’s “standards” are rife with unfair claims practices, untimely reviews, and non-existent ERISA appeals.

In my opinion, The Standard is eternally in violation of ERISA law. Not only does the company NOT disclose all information relied upon in making claims decisions, it alleges, “the claimant received a fair review, therefore, we don’t have to disclose anything.”

WOW. Just because The Standard alleges to have given claimants fair reviews it means they aren’t subject to ERISA laws? Now, that’s a first.

The Standard does not disclose copies of claims manuals, actual internal or outsourced medical/vocational reviews, actual communications. When requests for disclosure are received, the company  “tells” you what the medical reviews said, but won’t disclose the actual medical write-up. As an appeals expert working for attorneys I don’t accept what The Standard said was reported, I want to see the original medical review.

Forget it. The Standard continues to allege throughout the appeal in response to counsel that because the company gave the claimant a fair review, it doesn’t have to disclose internal medical, diary or vocational reports. In reality, such failures to disclose internal claim information deprives counsel and his/her insured of information needed to defend continuous payable benefits.

It’s also unclear to me whether or not The Standard affords insureds a fair appeal review at all. In my experience as a consultant, I have never witnessed The Standard over turn an unfair denial when appeals are filed. I’m sure they must overturn some, but I haven’t seen it.

The Standard is an arrogant company refusing to abide by ERISA disclosure requirements and does not, in my opinion, give claimants fair appeals reviews. Due to the fact that The Standard is one of the bottom feeder private disability insurers, violations go unnoticed and the company continues to violate the law.

If you have The Standard as your insurance company, I would make sure that the company abides by the policy contract and provides you with fair reviews. From what I’m seeing, The Standard has no standards.

 

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I wonder sometimes whether those who read my articles actually put my recommendations into practice. However, today I was made aware of a Unum denial letter that says, “because you were able to access, review and respond using Unum’s website, you do not have a cognitive condition.”

WOW. Unum recommends to insureds and clients that they use its website portal to communicate and then turns around and uses it against them? I have known about the tracking software for a long time, but this is a new low even for Unum.

Just so everyone understands…………Unum encourages use of its website portal and then uses it adversely to justify denying claims. DCS, Inc. clients are recommended NOT to use Unum’s portal. I am also told that once an account is created, it cannot be deleted.

The lesson here? DON’T USE UNUM’S WEBSITE PORTAL TO COMMUNICATE WITH THE COMPANY. This might be one time when those who read my blog actually listen to best advice. Unum actually cited use of the website portal as cause for denial.

In addition, I should also mention that social media such as Facebook, Twitter, LinkedIn and chat rooms should also be off-limits if you are receiving benefits. All of your social media is hacked, including the pages of your friends, and their friends, and their friends etc.

Is Facebook really worth risking your benefits?  Please do yourself a favor and do not use Unum’s website portal! If you have been using it, delete your computer cookies and history immediately. Then, insist on all communications in writing by mail.

Unum’s recommending use of the website portal, and then using it to justify claim denials is an unfair claims practice.

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Christmas GrinchThis time of year is extremely stressful for those who work in the disability claim areas of major insurance companies. Claims managers visit cubicles of employees armed with named targeted hit lists of those whose claims won’t be paid in the new year.

Already, CIGNA has emerged as the major harbinger of doom as the company continues to deny claims indiscriminately without investigation, cause or reason.

Obviously,  CIGNA’s 2013 Multi-State Settlement did nothing to improve the inefficient and negligent claims process that is earmarked by untrained, lazy and inefficient claims handlers. But, that doesn’t help claimants who are depending on benefit income for the Christmas season.

Unfortunately, MetLife, The Hartford and Mass Mutual are also pushing the boundaries of “claim target management” by requesting more IMEs, surveillance, field visits, questionnaires, and repetitive requests for patient files. If you’ve received multiple requests for the above since October, you are most likely a victim of year-end targeting schemes designed to deny claims when profits are most needed.

Reducing financial reserves and accumulating multiple profitability hits is a major objective of every disability insurer in the United States. For example, claims with over 1M in financial reserve will immediately contribute 1M to Balance Sheet profitability when they are denied.

You may have noticed I haven’t mentioned Unum Group thus far in this article and, well, in my opinion, Unum is still the Village looking for its idiot. Apparently, the company is lurching forward with Lucens requests for SSDI financial information in order to find a dollar here, and a dollar there, in overpayments it can recover.

Unfortunately, I’m still getting the impression that Unum is a company searching for its Leader who has gone off with an Atlantean alien to discover the ultimate Gnome on another planet. Outsourcing its operations to “black matter” in the universe doesn’t seem to be working all that well for Unum – at least so far.

Lately, playing “bad cop, good cop”, Unum tends to bend with the wind in its denials and doesn’t seem to have a distinct direction on anything. I’m sure Jim Orr III’s perception of his  former Unum accomplishments as CEO also agrees with mine in that Unum has gone from the “Lighthouse” to the “Outhouse” in a little more than a decade.

Still, Unum’s end of the year profitability targets continues to appear in the form of repeated questionnaires and doc-to-doc calls. Insureds and claimants should be wary of insurance doctors communicating denial agenda to treating physicians, who sometimes agree when pressured.

All in all, December is the primary “target” month for private disability  insurance leading insureds and claimants in “watchful mode” to prevent claims review abuse.

All insurance companies earn profit by NOT paying claims. And, I’s sure no one wants a claim denial delivered by their particular insurance Grinch during the coming holidays. If you need help, please give me a call.

 

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Recent news from inside Unum seems to indicate employees are given management directives to “do as much harm as you can.” Although some higher level employees are having pangs of conscience over Unum’s new “go get’em” strategies, most are content to harm insureds and claimants for a paycheck.

I don’t think I’ve ever heard of a disability insurance company that deliberately devises  outhouse strategies to “harm” insureds and claimants, but it doesn’t surprise me that Unum finally crossed that line. For years the company has been scamming its insureds by demanding repayment of imaginary overpayments suddenly turning up as a result of one re-calculation after another.

Robert C, [not his real name] was suddenly informed by Unum he owed over $250,000 because Unum made a mistake in calculation 12 years ago. Unprepared to repay such a large amount Robert probably won’t be paid a benefit for the duration of his claim. Unum eventually agreed to only collect 24 months of the new overpayments or $40,000, but Robert still won’t see a benefit for quite some time.

Of course, these focus initiatives are in addition to other unfair schemes within the claims review process such as multi-level medical reviews, rude claims handlers, and misrepresentation of information favorable to payment of claims. Recent information also suggests that management is training U-numbie newbies to presume all claims are fraudulent and investigate them as much as possible.

I think every Unum insured and claimant should stop and think about this for a moment. Not only does Unum want to deliberately do you harm,  the company teaches its employees to presuppose you are dishonest and treat you like a criminal. Your employer has definitely not done you any favors by providing you with group STD/LTD insurance you may never be able to honestly apply for, or receive.

As a former college educator and consultant I’ve tried to inform readers not to depend on disability insurance long-term. Although this is particularly true of Unum, other companies such as The Hartford, Prudential, CIGNA, Guardian and Mass Mutual have lowered their standards to meet Unum Group in the deception corner of the ring.

Disability benefits are no longer reliable as part of a financial planning portfolio. This is especially true of highly paid professionals who purchase IDI policies thinking Unum or Guardian will pay out on a $10,000-$15,000/month benefit without a fight.

What can you be thinking? Wealthy claims represent between 2-5M dollar financial reserves [contributions to profit if denied] and your claim will NEVER get off the “target” list.  Guardian and Mass Mutual are quickly following Unum’s unconscionable claims practices.

For now, in my opinion, Unum is causing its own insureds and claimants a great deal of harm. At least we now know what the big Lucens push for SSDI financial information was all about. In the last month DCS, Inc. received more than 10 calls about “fictitious overpayments” due to various Unum alleged “identification of errors.”

If Unum Group were an honest disability insurer I would report that too, however, that’s not the case. As a company Unum deliberately works against those it collects premium from. Insureds, claimants and their employers need to think about that. After all how often should you pay for the privilege of suddenly having no income because Unum alleges you owe THEM money and reduces benefits to $0?

I think it’s time for all Unum insureds and claimants to consider what’s at stake when a company deliberately investigates claims for the purpose of NOT paying, rather than paying claims.

Claimants and insureds are not without recourse in this matter. Claimants can contact their employers and let them know what Unum’s up to. Ask employers to make better choices by spending employee benefit dollars in more positive and reliable ways. Unum’s can’t stay in business long if the company can’t give away its STD/LTD Group Plans.

It’s easy for insureds – just don’t buy Unum IDI policies (if they are still selling them). If you have an old Paul Revere or Provident policy and need to file for disability, pay attention to policy provisions and force Unum to abide by the contract policy.

Obviously, Unum is out of control and thousands of claimants and insureds are at risk of losing benefits everyday. It’s own employees are calling the company out in negative ways because of its new policies of “going directly for the consumer jugular.”

In my opinion Unum Group is bad news for just about everyone.

 

 

 

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If I were a Guardian/Berkshire insured I would be very concerned and vigilant concerning the company’s interpretation of its policy provisions.

In the last two years I’ve had the opportunity to review several claim situations where Guardian’s claims reps deliberately misrepresented policy provisions in order gain profit advantage at the insured’s expense.

Company reps appear to be engaging in claims practices that are out-of-contract leading me to believe reps are acting on behalf of management directives rather than reading actual contracts. At least one attorney reported to me that she had to petition the state department of insurance to intervene when Guardian refused to pay a claim because the attorney had her client sign a limited Authorization. The DOI agreed with the attorney, but it took nearly 6 months to clear up the issue.

It has also been reported to DCS, Inc. that Guardian’s reps are extremely hostile on the phone when actions are challenged, even to the point of hanging up on the insured. I have personally experienced the same hostility with Guardian which actually does not serve the company well. Insureds who are patient enough to deal at all with Guardian on the phone should opt instead for written communications only.

I know of at least two Guardian claims where the company insists on deducting prior business losses that “do not result from disability” from the PMI calculation. The Guardian scam is to conjure calculate a percentage of prior business losses and apply it to the Prior Monthly Income calculation (PMI) so that in carrying non-existent business losses forward insureds are penalized for future losses that do not exist.

I also previously reported Guardian’s “over-the-top” investigation schemes that exceed standards of investigation normally assumed to be necessary for disability claims investigations. Whatever it is that changed the company’s popular status in the disability insurance industry from 2nd behind Northwestern Mutual to a notable “bad faith” insurer is now obvious to most professionals looking to buy disability protection.

Unfortunately, I would not recommend Guardian’s disability policies to any professional given the company’s current erratic patterns of enforcing policy provisions to favor future business losses that do not exist.

The company is no longer reputable as a seller of disability protection because it no longer adjudicates claims in “good faith and fair dealing.”

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Scam alertGuardian has always been an “investigative overachiever”, but in its search to determine total disability vs. residual disability the company often interprets no earnings as “negative earnings”, which in my opinion is a misinterpretation of policy provisions and a breach of contract.

Insurers often have a vested interest in paying residual vs. total disability because the distinction could affect the amount and duration of future benefits by paying for shorter duration or not all, or limiting the time residual benefits can be paid.

In the case of Insured A who is performing her own occupation as a dentist part-time and not performing orthodonture, and receiving no income, it could be to Guardian’s advantage to determine payment should be made for “residual benefits” even when there are no earnings. And, this is a bit of a problem.

First, Guardian’s policies define “residual earnings” as “gainful part-time work.” Logic dictates that “no earnings” isn’t gainful. Therefore, also logically in order to pay “residual benefits” there must be gainful earnings.

A second problem arises when the residual computation outlined in the policy is calculated to determine what is owed. Guardian would need to input a $0 earnings figure, hence the result referred to as “negative earnings.” What this means to the insured is that a “negative earnings” figure most likely results in the payment of 100% of benefit representing no change to the insured in the present. BUT, if the policy limits or reduces “residual benefits” in the future, the insured could be penalized.

I can foresee Guardian saying to Insured A, “We’ve decided to pay you under the residual provisions of your policy, but don’t worry since you’ll still be paid 100% of your benefit.” Most insureds would agree without reading the remainder of their policy writing indicating a limited pay period for residual disability, or lesser benefit in the future.

In my opinion, in order to be paid under the residual provisions of a policy THERE MUST BE  GAINFUL EARNINGS. There is no such thing as negative earnings by policy definition. Insureds are recommended to read the residual provisions in their policies very carefully to determine “what happens” in the future when paid residually.

It just doesn’t make sense to pay insureds 100% of residual benefits when there are no earnings producing “negative income” in the computations. You must know there must be an otherwise advantageous profitability reason why Guardian would do such a thing.

Insureds who are working part-time, perhaps in their own businesses, but not receiving income are still totally disabled because they have at least a 20% earnings loss and are performing their occupations for less time than is normally required. Attorneys need to challenge this in the courts if they get a chance to do so.

This strategy borders on bad faith since it appears to be  a “pattern of business practice.”

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