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Archive for the ‘Case Stories’ 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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If you ever wanted to know the tragic effects of Unum’s hunt to recalculate claims long-term for non-existent overpayments please read the email sent to me below.

“I am attaching a message I wrote to a friend just for the sake of telling you what is going on. I am another victim of UNUM. I’m about to have my 66th birthday and after years of battling these people they have struck again. If you would be so kind as to review this short version and let me know if I have recourse or who I can contact to help me I would really appreciate it.

I had the worst thing possible happen this past week. Years ago when I was forced into medical retirement,  the plant gave me my retirement and submitted me for disability insurance. I had paid for it for years out of my own pocket but never saw a policy or knew much else other than what they had said to promote it. They told me when I signed up it was for 60% pay replacement.  

When I met with the Human resources rep for the company I was told I would receive my retirement as well as the UNUM insurance benefits which would equal about what I was currently making. I was so happy that I had paid for the UNUM disability insurance all those years. Other than then I had to start paying about 8 times more for health insurance, I was receiving close to what I did while I worked.

I never questioned it at all or had a second thought. After about 2 years, Unum contacted me and said that they had learned I was getting income from my retirement and that it hadn’t been discounted from my benefits.  So they had said they had over paid me some $20,000 dollars. Even though the amount was reduced by counting my retirement as income,  they took back what they were supposed to pay me and kept it. Now mind you, I had paid taxes on all this. And my income from Wolf Creek was nothing, because once I was retired my health insurance took all but a couple hundred dollars a month from my retirement.

So virtually I was receiving very little income other than social security.

UNUM told me when I turned 65 that I would still owe them about $4000 even though I never got money at all for several years. Last year for some reason they deposited $7 or so into my account per month without a letter of explanation or anything. I had heard that  last year there was a big lawsuit against UNUM and they were ordered to repay millions of dollars to people whom they had scammed out of disability benefits. I heard nothing more from them and my usual forms for the doctor to show I still qualified for disability didn’t come.

Finally, nearly a year later I had relaxed and decided that they had tried to scam me as well and I finally decided I didn’t need to worry about them. Well this weekend I got a letter from them saying that I owe them $4700 and they’d be contacting me for payment. First I have no idea why the amount is higher. Secondly I didn’t expect it, and thirdly I don’t just have that kind of money laying around.

I’ve been rat holing some money so I could afford to go to the dentist since my teeth are trashed and I can’t wear my partial any more. And I need new glasses but hated to spend the money to get them.

Well obviously that wasn’t enough to cover those expenses anyway, and now I have to come up with a lot more money to get these people off my back. So I guess I am supposed to give up being able to see and to eat so I can pay them back.

I also have never seen or read the policy for this insurance. All I had to go on was what I was told by Wolf Creek. Back when this first letter from UNUM came several years ago I talked to a benefits representative for the company I worked for Wolf Creek Nuclear, and she said I had no recourse and that I had to pay it. I had called and talked to an UNUM representative on the phone and asked why other people who had been put on medical retirement were getting their retirement as well as the full 60% pay replacement from UNUM She said that it was none of my business and she wasn’t obligated to explain anything.

When this first came up I called virtually every attorney I could find to see if someone would represent me and not a single one I talked to would look into it.

 I tried to contact the insurance Commissioner’s office as well and was basically told that it was impossible to meet with him. I found that no matter what I was helpless and had no way to fight this.

 Once again I am all stressed and wondering how on earth I’ll pay them off. I absolutely refuse to make payments and therefore short myself even more every month. So I guess my only option is to start selling whatever I can to make money.

 My friend sent me a link to your page. If there is anything at all you can do to guide me to help me I would really appreciate it.”


(This is a very tragic story in that this claimant can’t even interest attorneys to assist her. In the end Unum’s persistent financial reviews to hunt down every lost nickel and dime characterize the company as an unfair, egregious insurer. Unum’s endgame, of course, in requesting SSDI Authorizations to obtain financial information, is to allege overpayments it cannot prove, but fully intends to collect.
No employer at this point should be purchsing any group product from Unum Group. It’s just not worth it to employees anymore.)

 

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Here is a story published by the Philadelphia Inquirer sent to  me by a Client. Thank you!

http://www.philly.com/philly/health/depression-mental-health-disability-insurance-denial-20180509.html

 

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Please read below the account of one insured’s experience with Student Loan forgiveness for total disability. It seems to me the “deal” isn’t what it’s cracked up to be.

Submitted by a blog reader and supporter. Thank you.

“I just have to vent about how disturbing the whole student loan disability process and how unorganized and  untimely it really is.

Forgiveness of student loans by reason of total permanent disability is handled by a company called Nelnet. They claim they are the exclusive provider of this service for the US Department of Education. When your loan is forgiven, you have to make less than the US poverty level for 3 years, otherwise your student loan is reinstated.

Three years ago when my loan was forgiven eveything went fine. But then, as you warn on your website, I claimed too much income (wife’s job) and my loan was reinstated. 

I do not believe Nelnet has any access to tax records. They just ask you to sign a statement that you didn’t work, or if you did, how much. I regret so much we answered that truthfully.

If you make too much, then you have to pay the loan again, and Nelnet gets the money. See the conflict of interest? Nelnet gets the money if your loan is reinstated, and they are also the one to decide if you are too disabled to work. They don’t do medical reviews, just doctor signature on the form or SSDI with a 5 or 7 year medical review (we are 3 year). So their only weapon is a delay.

It took them a few months, but many months ago, they claimed to be starting the reinstatement of the loan, with them as the collectors. I completed a new disability forgiveness paperwork and had the doctor sign it. Submitted it quickly. On the new applications, they have a 4 month timeline, but on these reinstated applications, they make clear on the phone they have no requirement for when they will review them. They will hold off requiring payment on the loan for 4 months, but after that, they want payment.

It’s been more than that. They STILL haven’t processed the disability application. They claim their Information Technology Department is still working on it. But the loan servicing part says a payment is due just a few weeks from now. I tried calling and asking for a forbearance for reason of disability. She granted a one month reprieve on the loan payment, with longer available after they review documentation. Nelnet insisted they needed the original SSDI approval, not a current statement (printable of the SSA website). The next day, they rejected it as too old. More significantly, the loan payment date changed, from in a few weeks to now PAST DUE of $50 with another payment due in a few weeks.

It makes me so mad that they can take forever to process this disability application claiming their Information Technology Department is working on it, but require payments from the loan which clearly the Information Technology department already worked on. And then make due dates earlier and claim something is past due days after saying it was due in a few weeks.”

(I think in cases like this I would give my Congressional Senator a call for assistance. Technically, these untimely decisions could result in Nelnet compensating you for interest on all of the payments you’ve made since requalifying for loan forgiveness. Give your Senator a good swift kick in the butt to do some work for a change and help you resolve this mess!)

 

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MetLife’s reputation as an unfair disability insurer was well-earned today and the company’s representatives should be ashamed of themselves. I received a call from one of my insureds who was recently diagnosed with cervical cancer and recently came out of surgery in a great deal of pain.

She asked me, from the hospital, to contact MetLife and ask for an extension for sending in her forms which she had been working on prior to the new diagnosis and surgery. She was not able to speak to me for long and I could tell she was in a great deal of pain.

I contacted MetLife and began speaking to a Customer Service Representative. I tried calling earlier, but received a busy signal when I entered in the claims handler’s extension. This time around I opted for the Service Rep. who when I informed her that my client had been hospitalized and received surgery promptly said rudely, “So when is she going back to work?” With that, my response was, “Excuse me?”

One of the things I say the most on the blog is, “Disability insurers know nothing about disability”, and to be honest, as a consultant, I find myself often defending the rights of disabled insureds to be treated with respect and compassion. When I asked to speak with a supervisor I was told that “someone would get back to me”. In essence, the manager refused to handle the problem.

Later, I did receive a voice message from the original claims handler, but when I returned the call she didn’t pick up. The customer service rep was rude, continuously spoke over me, and just wanted to know “when she was going back to work.” Incidentally, this claimant has been on claim for about 10 years now for another impairment, so the issue of return to work wouldn’t have been relevant anyway.

Apparently, in order to get an extension for paperwork, I would have needed to tell the rep when my client’s next doctor’s appointment would be – yet another really dumb question for someone who just came out of surgery.

The only time I could get the rep to be quiet was to finally say to her, “Do you not care about Marcy?” (Not her real name.) There was a quick moment of silence before the rep again chatted incessantly over me about next appointments…when did she last see her doctor etc.

I would like to share with those of you managing your own claims that there should never be a time when your insurer should be allowed to treat you with disrespect and lack of compassion. In fact, for my clients, I defend these basic rights every time I come across claims handlers, who above all else, lack basic qualities of human compassion.

What would have been so wrong for MetLife’s rep to simply say, “I’m sorry, Ms. Nee, that your client is having such a hard time. I’ll make sure your request is documented and sent to the claims handler. She will probably get in touch with you about the extension. Thank you for letting us know.” Do they not think?

In any event, I consider MetLife’s handling of a simple notification of hospitalization and surgery to be an unconscionable disgrace.  Those who know me can probably guess what my next step will be.

However, please know that all insureds and claimants have the right to be treated with dignity and respect when you contact your insurers. As a claims consultant, I insist on that basic right every time.

 

 

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Most of us already know the devastating effects of trying to obtain health care under our current systems in the United States. Despite a growing disparity in the Healthcare Marketplace, the issue of health care has become a real political issue that half of the country isn’t happy with.

Here is an email I received. It portrays a sad situation, however, some US citizens are considering immigration OUT of the United States to Canada just to receive proper medical care. From what I’m hearing, other than medical care, Canada might not be a good choice to establish permanent residency considering other aspects of life.

“… I have traveled and am arranging to relocate full or part time to Canada and am looking at cities and immigration options. I had one doctor say I have kidney disease, overfunctioning, in 2013 and gross overfunctioning reverified by a test in the past year.

The good news is I thought diabetes would rule me out of immigration there but a doctor said they don’t rule out for diabetes per se (they invented insulin and it is affordable unlike the US)  but body organ damage specfic to kidneys and creatine test would keep me from immigrating, as well as possibly age. So I am checking. The good news is my creatinine test has generally been normal, close to abnormal or within normal ranges so I would not be automatically ruled out if it tests ok on the  normal tests. I hope US and Canada have same standards. I did have higher readings last test just a little above normal but the nurse who read it  said it is considered normal enoughl. If I look to immigrate, I feel I need to do it now before that body organ damage occurs and keeps me here forever.

They were so nice and helpful. I feel safer. I had hypos and they helped, got direction, helped me get a gratis lancet device, retail humalog 325 or 350 usd here and about 25 usd there. I was sick a bit of trip and stayed in recovering from gross glucose and they were so helpful. Dropped an insulin vial when I went low and they found it and remembered me and got it back to me.  I was impaired and they were just nice and safe.

In the US I have been slapped by a first responder firefighter when I was low, separated from my glucose meter and insulin by police by their unawareness and luckily I was well enough to get it back, I was left to get no help not even 911 when I started to go into a hypo in a taco bell drive thru driveway where I live, too impaired to remember I had glucose, and I was run through the ringer with 4 cancer scares and then a  precancer scare the last 2 years luckily mostly clear except for the mass amount of radiation (in Canada there is medicine that reduces dna damage from ct scans by half, and not approved here btw), an awful and totally preventable hospitalization if I was properly diagnosed, and meeting catastrophic limits the last two years for all this insane care. “

Again, this is a sad situation, but for some people the only option.

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Sometimes I wish I could be the fly on the wall at Unum when certain situations hit the fan. It’s not that I want to gloat, or “rub it in”, or even find some new way to discredit Unum, but on behalf of insureds and claimants everywhere to be able to say, “we gotcha!”

Sometimes things do not work out the way Unum wants them to. For instance, I’m reminded of a female client who, for the last 6 months at least, was harassed, threatened, suffered an unjust SSDI estimate removed from her benefit, filed a complaint, and finally yesterday was awarded SSDI benefits.

This particular client, (let’s call her Mary X), filed for benefits sometime in January and immediately became the recipient of Unum’s chasing for constant updates. Lately, Unum’s strategies are to send out threatening letters advising that if they do not receive SSDI updates immediate estimate reductions will take place.

I’m sure Unum’s motivation revolved around the client’s date of disability in 2014 and the possible award of at least $2,400/month from SSA. That’s nearly $86,000 in retroactive overpayments and, of course, Unum couldn’t allow any claimant to keep that amount of money or risk the claimant spending it.

Unum began offsetting my client’s benefit in an out-of-contract move to at least benefit by reducing the financial reserve. After my client decided to file a complaint for breach of contract, and with my help, Unum refunded the estimated amount but continued to allege that “because SSDI decisions usually took 10 weeks (where did they get that information from?), it intended to offset for another estimated amount.

Please believe me when I tell you that Unum left no stone unturned in continuously harassing and causing my client financial harm because of the as yet un-awarded SSDI benefit.

Yesterday, we got word from SSA that my client’s application for SSDI was approved but that she became eligible for benefits in May 2017 and is eligible for benefits beginning October 1st. (Remember the 5 month waiting period?) My client would receive $2,498 beginning in October 2017. Period. This outcome was not a surprise to my client who was hoping Unum could not benefit from taking a large overpayment from her.

Oops. Is Unum still looking for the large overpayment? Since my client had not yet received her October benefit check, no overpayment is due.  The only thing Unum is going to get out of all of its hard work is the future offset from benefits.

As I said earlier, I sometimes wish I could be a fly on the wall to observe the “No $200 Pass Go” looks on the faces of those who worked so hard to harass claimants toward company goals. Gosh, that’s probably a big disappointment!

If Unum’s Offset Coordinator hadn’t been quite so aggressive and harassing about chasing SSDI I would have considered this situation more normal and customary.

Still, a smiling fly on the Unum wall once in a while probably isn’t a really bad thing!

 

 

 

 

 

 

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