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Archive for the ‘Breaking News’ Category

As most of you should know the proposed ERISA changes intended to go into effect on January 1st were extended to April 1, 2018. The extension was caused by the insurance industry’s opposition to changes that would “cost them more money”, or “cause the elimination of disability insurance offerings.”

Of course we can all assume that the real reason for the opposition is that the proposed ERISA changes provide an even playing field for claimants and make it more difficult for insurers such as Unum, (a company opposing changes) to deny appeals.

Lately, DCS Inc. has been receiving calls from claimants telling me that attorneys, who formerly refused to accept their cases, are calling them marketing their services under the proposed new regulations. I also heard from several sources that some attorneys are putting forth the changes when they aren’t even effective yet.

Wait a minute Esq.’s! The ERISA changes won’t be effective until April 1, 2018, if in fact they are approved. Try as I might to find ways to be kind to attorneys on the blog, I think over booking the ERISA changes prematurely, or marketing future services based on the proposed changes sounds a bit like a squeaky wheel to  me.

In any event, please see the proposed changes listed below. If these changes do go through the Department of Labor claimants may finally get an even playing field in the ERISA claims review process.

Disclosure Requirements.Benefit denial notices must contain a more complete discussion of why the plan denied a claim and the standards it used in making the decision. For example, notices must include a discussion of the basis for disagreeing with a disability determination made by the Social Security Administration (“SSA”) if presented by the claimant in support of his or her claim. (Actually, Unum already does this and has a scheme in place to “not consider” SSDI decisions.)

Claim File and Internal Protocols. Benefit denial notices must include a statement that the claimant is entitled to receive, upon request, the entire claim file and other relevant documents. Currently, this statement is required only in notices denying benefits on appeal. Benefit denial notices also must include the internal rules, guidelines, protocols, standards, or other similar criteria of the plan that were used in denying a claim, or a statement that none were used. (Internal claims manuals etc. would need to be provided.) Currently, denial notices are not required to include these internal rules, guidelines, protocols, or standards; instead denial notices may include a statement that such rules, guidelines, protocols, or standards were used in denying the claim and that a copy will be provided to the claimant upon request. (Insurers may decide to republish their benefit claims manuals to remove process disclosure. Some companies such as Lincoln Financial and Liberty Mutual will have a problem with giving up this information.)

Review and Respond to New Information. Plans may not deny benefits on appeal based on new or additional evidence or rationales that were not included when the benefit was denied at the claims stage, unless the claimant is given notice and a fair opportunity to respond. (This suggests that appeal denial decisions must be based on whether or not the original denial was the right decision to make. Many insurers engage in ad hoc investigations to obtain new evidence to deny claims.)

Conflicts of InterestPlans must ensure that disability benefit claims and appeals are adjudicated in a manner designed to ensure the independence and impartiality of the persons involved in making the decision. For example, a claims adjudicator or medical or vocational expert could not be hired, promoted, terminated, or compensated based on the likelihood of the person denying benefit claims.

Deemed Exhaustion. If a plan does not adhere to all claims processing rules, the claimant is deemed to have exhausted the administrative remedies available under the plan, unless the violation was the result of a minor error and other conditions are met. If the claimant is deemed to have exhausted the administrative remedies available under the plan, the claim or appeal is deemed denied on review without the exercise of discretion by a fiduciary and the claimant may immediately pursue his or her claim in court. A plan also must treat a claim as re-filed on appeal upon the plan’s receipt of a court’s decision rejecting the claimant’s request for review.

Coverage Rescissions. Rescissions of coverage, including retroactive terminations due to alleged misrepresentation of fact (e.g., errors in the application for coverage) must be treated as adverse benefit determinations, thereby triggering the plan’s appeals procedures. Rescissions for non-payment of premiums are not covered by this provision.

Communication Requirements in Non-English LanguagesBenefit denial notices have to be provided in a non-English language in certain situations, using essentially the standard applicable to group health benefit notices under the Affordable Care Act (“ACA”). Specifically, if a disability claimant’s address is in a county where 10 percent or more of the population is literate only in the same non-English language, benefit denial notices must include a prominent statement in the relevant non-English language about the availability of language services. In such cases, plans also would be required to provide oral language services in the relevant non-English language and provide written notices in the non-English language upon request.

Claimants should be aware that these proposed changes, if approved, won’t be effective until April 1, 2018. In my opinion it is unethical for attorneys to be marketing their services based on changes that are not yet approved or in force. If you receive any cold calls from attorneys on this matter, tell them to take a hike, at least until April 1st.

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Thanks to an insured who sent me this very important link. If it acts like a duck, quacks like a duck, it’s probably fraud.

https://theintercept.com/2018/01/11/aflac-fraud-lawsuit-sales-associates/

 

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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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Several times this month I’ve received phone calls asking me to recommend insurers for both Group STD/LTD and Individual Disability. While the disability insurance industry is corrupt as a whole there are insurers who engage less in bad faith than others.

Here is my top 20 ranking for 2017 beginning with the worst insurers.

 

 

  1. Unum Group
  2. Prudential
  3. CIGNA
  4. Met Life
  5. Aetna
  6. The Hartford
  7. Mass Mutual
  8. Sedgwick/The Reed Group
  9. Guardian/Berkshire
  10. Disability Management Services, Inc.
  11. RMS
  12. Ohio National
  13. Mutual of Omaha
  14. Lincoln Financial
  15. Liberty Mutual
  16. The Standard
  17. Standard Reliance
  18. Aflac
  19. Principal
  20. Northwestern Mutual

While there are no real “better” group STD/LTD insurers, the Individual Disability market shows both Principal and Northwestern Mutual to be fair reviewers of individual disability claims. Congratulations to NWM and Principal for continuing to perform objective claim reviews in 2017!

In my opinion, the “Top 10” listed are not fair disability claim reviewers and should not be considered to be fair in any aspect of claim investigation.

 

 

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You're Fired2

Unum Firings – No Job Security

Unum insiders continue to report the company is still terminating employees, mostly women over 50. Unum is well-known for its terminations of mature women spanning a decade or more. The company’s mantra is to target females over 50 by padding personnel files with issues alleging “poor performance.”

Unum isn’t the company for females looking for job security. Current employees continue to report lack of upward mobility for most claims personnel. In addition, Unum does not approve employee FMLA and STD claims even for its own. Instead, employees who go out on medical leave are quickly disposed of through the auspices of “poor performance.”

Unum is NOT a good place to work since claims handlers are repeatedly forced to watch their backs in addition to performing jobs that are extremely stressful. My impression when I actually worked for the company was that those who picked the toenails of managers were promoted and pushed ahead even though most were one taco short of a combination plate! Hence, Unum’s frequent lack of knowledgable leadership.

Unum’s continued fast forward to outsource most work leaves little expectation of job security for those who remain employed, at least for the time being.

PA1959Pennies From Piggy Banks

Unum insiders are also reporting the company’s “hunt and peck” for SSDI monies owed may be including COLA specifically excluded as an offset in all ERISA Plans. It’s unclear how complicit Lucens is in the scheme to find “a dollar here, a dollar there” overpayments.

Claimants should always request Unum “to prove it” [overpayments] before agreeing to pay back any money. Requesting SSDI 1099s does not separate gross benefit from COLA; therefore, it’s a mystery why Unum even requests the 1099s.

Still, there is usually no logic to Unum’s schemes other than to bolster profitability. Unum should always be asked to “put up, or shut up” when it comes to allegations of owing money. The Financial Department’s efforts to hunt down pennies out of SSDI award piggy banks is an indication of how badly the company may need the money.

“It’s All In Your Head”

All in your headThere are also recent reports that Unum Group fully intends to use the “self-reported” language in its Plans and policies to deny claims particularly for fibromyalgia, chronic fatigue and possibly memory and cognitive issues, Lyme disease, depression, and any other impairment it can throw under the bus.

Anytime a disability insurance company reviews claims with an objective of denial rather and approval, it can be reasonably said the company is engaging in unfair claims practices. To seek out legal support in various states that will support such tactics is a deliberate effort to target certain impairments and classify them as “self-supported.”

Fibromyalgia and chronic  fatigue have always been challenged (particularly in the UK) as “fake” or “somaticized” impairments. The new DSM 5 suggests that anyone who is worried or preoccupied with anything that’s wrong with them is also crazy. Clearly, one has to question the classification of somatic illness when it’s defined as worry, preoccupation and overindulgence with symptoms imagined or real.

Seems to me the current DSM 5 definition of somatic syndrome leaves the door open to classifying nearly everyone as mentally ill. Needless to say, it looks as though Unum is back to its nasty tricks of alleging physical disease is “all in one’s head” in order to avoid payment.

corporate theft SSDI Hold Ups For Repayment

Unum’s Financial Services Department does not get a gold star when in comes to chasing down SSDI overpayments from claimants. Representatives are pushy and demand repayments via threatening letters and demands for repayment.

This particular issue was brought to my attention when demands for repayment of SSDI money not received crossed the line of fair review. First was a situation wherein Unum’s reps attempted to use, “Well, SSA usually makes a decision in 4-6 weeks and your application is over 3 months old….we’re going to offset your benefit with an estimate” as a threat.

Second, Unum demands repayment under threat of offset even when the claimant hasn’t yet received any money from SSA. Claimants cannot pay what they do not yet have, simple as that. Yet, claimants are often penalized with offsets prior to receiving any actual money to pay back.

Is Unum really that hard up for money? The company’s new tactics and objectives are about as far away from good faith and fair dealing as they can get.

 

 

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DCS has been getting many inquiries concerning the letters Lucens is sending out asking claimants to sign Authorizations to obtain SSDI financial information. These requests are making some claimants very anxious. Therefore, I want to be very clear about what claimants’ rights are under the provisions of their Plans and policies.

To my knowledge no where in any of Unum’s ERISA Plans does it require claimant’s to release SSDI information. This includes any part of the SSDI file whether it is medical or financial. Claimant’s may choose to keep their SSDI file private and choose not to release any part of it.

Recently, Unum has joined forces with a company called Lucens to obtain financial SSDI information presumably for the purpose of recalculating offsets to identify large overpayments that are owed back to the company. Periodically, Unum begins these “financial recalculations” as a company wide initiative to reduce benefits to $0 to recover alleged overpayments that do not exist.

I am assuming that while Lucens is requesting SSDI files from the ERISA folks, IDI handlers are requesting extensive previously tax returns from those insureds who worked residually. Insureds who have been residually employed are at risk most, since a nefarious re-calculation of PMI (Prior Monthly Income) by Unum (or Lucens) could allege 6-figure overpayments.

But, to be clear, neither claimants nor insureds are required to sign Authorizations releasing any information to Lucens or Unum. Individuals can respond to the Lucens letters by faxing a response informing them you do not wish to sign the Authorization or release any information.

Having said this, Unum IS entitled to have a copy of the original SSDI approval letter that is quite informational and contains all of the information Unum needs to calculate overpayments, attorney’s fees, and initial benefit amounts. Unum’s ERISA Plans do not offset COLA amounts.

End of the year 1099’s from SSA do not break out COLA amounts paid from total payments, therefore I’m wondering  for what purpose Lucens wants to see SSA 1099’s. They would be better off referring to initial approval letters that have the needed information.

I suspect Unum is also concerned about SSDI increases due to additional earnings, or worker’s compensation adjustments. Calculations of benefits paid (using new methods) can produce any result. Years later, Unum calculates again and still finds additional overpayment. It’s a never-ending process to avoid paying benefits due.

Generally accepted accounting principles include a “Continuity” requirement that ensures consistency in calculation and methodology in the financial records. For Unum to recalculate benefits and offsets every few years for the same claimants and insureds is a violation of “Continuity and Consistency” in financial reporting.

Asking yourself why Unum is engaging in this focus initiative? To find money….to bolster its profitability, reduce monthly benefit payments to $0 and improve its cash flow. The money trail is always a good indication of why Unum engages in any new focus project.

 

 

 

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Readers may recall in a previous post that Unum deliberately deducted an estimate from a client’s benefits for estimated SSDI. After two months of taking the estimate, Unum at first refused to stop the deduction and pay back what it took out-of-contract.

After several letters from my client requesting reimbursement and interest, Unum agreed to repay her for the estimates taken in error and actually paid interest on the amount over 30 days.

Make no mistake, Unum didn’t send the reimbursement without a fight, but in the end Unum agreed the estimate was taken in error. My client was properly advised by DCS as to her rights and provisions under her employer’s Plan, and she brought the proper arguments to Unum’s attention along with a copy of a complaint made to the State DOI.

After written notification, my client sent me the following email: “Unum deposited over $5,000 today in to my checking account! As usual, your advice concerning my policy paid off. Thank you, Linda, for properly advising me!”

While my opinion of Unum’s tactics isn’t changed, in the interest of fairness it’s only fitting that I recognize the claims specialist from Unum’s financial department who made good on the error.

At least for now, it seems as though even the bad guys can make things right!

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