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Archive for the ‘Claims Process’ Category

It is not uncommon for those who are insured under ERISA Plans, or IDI policies to have unrealistic expectations of the products they, or their employers, pay for. From the beginning, insureds/claimants perceive the words “benefits”, “own occupation” and “employee benefit” as certainty that benefits will be paid when needed.

Nothing could be further from the truth. ERISA Plans are deliberately written with provisions that limit benefits to 60% of pre-disability earnings, as well as other writings that are adverse such as “offsets”, or reductions in benefits, and limitations for mental health illness. In addition, ERISA Plans often come ready-made with “discretionary authority” statements that gives insurers the right to decide who gets paid and what the Plan means. These things are just as true when employees first become eligible for STD/LTD coverage as they are when claims are filed in the future.

IDI policies have misled many professionals and highly paid executives into thinking they are given an “edge” on benefit payments and should receive 100% of total disability benefits when returning to work in alternative occupations. Policies containing “Residual Benefit” provisions are enlightening and surprising to those who think “own occupation” gives them 100% of total disability benefit. Also not true.

Here is a list of what private disability insurance is NOT. Hopefully, you will take a moment to think about this.

  • Disability insurance is NOT an entitlement. Insurance premium is a payment that covers the cost of assuming risk over a period of time. Unlike SSDI or SSR, your premium isn’t paid into a program that “entitles” you to benefits at a certain age or disability. Just because you’ve been paying premium over a long period of time, doesn’t “entitle” you to anything. The best thing you have is a promise to “good faith and fair dealing”, if in fact you get that at all.
  • Disability insurance is NOT dependable. Insurers “risk manage” claims for the intended purpose of reducing the actual number of claims paid. This is how disability insurers make their money. If they paid all claims that should be paid, and deny those that should be denied, they still wouldn’t be profitable. It is only by devising strategies to deny legitimately payable claims that produces profit – therein lies the profit margin.
  • Disability insurance benefits are NOT fixed. ERISA plans in particular “offset” or reduces benefits for other monthly earnings such as workers’ compensation, SSDI awards, both primary and family, retirement distributions etc. Plans only pay 60% of pre-disability earnings (a loss of 40% coming out the gate), and then further reduce for other sources of income. This is something families with dependents  and retirees should know from the beginning.
  • Disability benefits are NOT always tax-free. ERISA benefits are taxable to the extent the employer pays the premium. If your employer paid for your Plan, benefits are taxable. If you paid the premium for your IDI policy, benefits are tax-free. If you paid premium with pre-tax dollars, benefits are taxable. Consider – you have an ERISA Plan paid for by your employer AND you are awarded SSDI – both taxable. How much money are you really ahead?
  • Disability Insurance is NOT intended to last to maximum duration. Disability insurers actively take all necessary steps to invalidate and discredit claims so they do not have to pay them. Any insurer who winds up paying a claim to Lifetime or Age 65 considers it a loss situation. The probability of receiving benefits to Age 65 is less than 30%, based on my own knowledge of what gets paid and what doesn’t.

Although I could go on, I think you get the idea. So many people tell me, “I have to continue receiving these benefits or I’ll be out in the street”, or, “I don’t know what I would do if my claim is denied.”  The truth is, disability insurance isn’t reliable, secure, fixed, guaranteed, or assured.

Insureds/claimants often do not have realistic expectations about what private disability insurance really is. Therefore, at some point, it becomes clear that what was once thought to be a benefit, isn’t really, and reality sets in.

I hope my readers hear the message of this post loud and clear and begin planning alternative sources of income for the future. Putting all of your chips in the private disability basket may not be a great way to high stake your finances in the future.

Please give this some thought.

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One of the topics I have not addressed in a long time is the issue of Unum’s use of barcodes on its forms. Unum insureds and claimants should be aware of the fact that the company’s update forms contains barcodes on the upper right corner of each form with a long number underneath. Go ahead….if you have a few blank Unum update forms around, check it out!

While it is widely accepted that insurance companies are “paper crunchers”, recent speculations of what financial, personal and health information is going where raises the questions of how insureds are identified on the update forms.

For example, who or what codes the barcodes, what information does the barcode contain, what happens to the actual “paper” form after its barcode is scanned, etc. Wouldn’t you be interested to know what information is floating around via this barcode? Or, where the information is electronically sent?

When I worked for Unum there were no barcodes. Paper update forms came into the company and were forwarded or assigned to a claims handler. Later, each piece of paper was scanned and sent electronically to a claims handler’s desktop. Apparently, at some point Unum made the decision to barcode its update forms.

Consider. Unum recently removed its IT division to India. Employees complain Unum still uses out dated technology and is extremely disorganized. How is the company managing barcoded information, and what confidence would you have in a system run by a publicly recognized negligent and chaotic company?

Although we just don’t know what information the barcode contains, and putting aside any scary implications of conspiracy of giving information to government agencies, it is a bit disconcerting that insureds/claimants/patients are not told the significance of the barcode, what purpose it serves, and what information it contains.

A question I’ve had for a long time is, (and this may pertain to other insurers as well), what happens to the actual “paper” documentation if everything is electronically scanned and sent electronically to reviewing resources? Also, since insurers are now opting for third-party reviewer facilities, what happens to documentation sent to them, and what do they do with the barcoded information? How long is it kept on file? How is it discarded or destroyed?

We know that basically HIPAA is a failed piece of legislation since HIPAA approved Authorizations themselves tell you once information is released it loses any protection it had, if any. Another question might be whether barcoded health information is HIPAA protected, or like many other aspects of private disability claims management, it is excluded from privacy at all.

In my opinion, there are far too many questions surrounding Unum’s use of barcodes.  DCS, Inc. does not submit forms for clients with barcodes. Clients have a right to know what information is coded on the update forms, but I’m guessing claims handlers wouldn’t be able to tell you, since they too are kept in the dark.

Any information, whether it’s asked outright, or hiding in plain sight should be disclosed to insureds and claimants. Barcodes are obviously “hiding in plain sight”; rarely do insureds pay any attention, having already been conditioned to having UPC Codes on everything we buy.

Remember though…barcodes contain information. Wouldn’t you like to know exactly WHAT information is coded on the forms? I know I would.

 

 

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This morning I spoke with someone who told me that he calls Unum on the phone and speaks to the representative quite often; he does NOT have a copy of his employer’s Plan and has never read it; uses Unum’s website portal for communications which he checks at least once a day; uses Facebook to speak with his family; and doesn’t think he has anything to worry about because he doesn’t do anything wrong.

Wow. My first reaction is that the gentleman caller has a great deal of trust in an insurance company doing its best to not pay him. I realize that not everyone has access to Lindanee’s Blog, but seriously?

Although I have said this on many occasions, I probably should say it again. Insureds and claimants cannot defend what they haven’t read, or have possession of.  Insureds couldn’t even verify that policy or Plan citations in letters are accurate, or if Unum calculated the Elimination Period correctly etc. Taking any private disability insurer “on faith” is a very naive mistake.

Consider. I received several phone calls this week from those who told me, “I spoke with my Unum representative and he told me………”, which when I heard it, knew it to be wrong. Unum reps aren’t trained to adjudicate disability Plans and policies and therefore they aren’t knowledgeable enough to answer contract questions.

Yet, even after I informed the caller of the correct information, he still wanted to believe Unum. I guess  as a Consultant, there are some things I just can’t change. This particular caller was receiving $4,000/month in benefit and was risking around $500,000 in future benefit. Naïveté can be costly.

Copies of ERISA Plans should be provided at the time of annual enrollment, an ERISA requirement most employers don’t know about, or don’t want to know about. Bottom line, given the total financial reserve of private disability today it’s costly to NOT know what’s at stake and how the process works.

In addition, let me say that my client list includes claims for attorneys, plastic surgeons, scientists, engineers and others who are well-educated and credentialed. Private disability can be an equal credential spoiler.

The best educated insureds who are naive about the claims process are more likely to lose benefits because he/she believes their education makes them qualified to manage their own claims. In today’s world it is more likely than not that insureds seek additional information and assistance to ensure payment of legitimate benefits – regardless of educational backgrounds.

Finally, insureds need to understand from the beginning that private disability insurers lie to you about most things. In order to deny more and more claims, insurers continue to devise claims review strategies that misrepresent information and “position” arguments in highly covert and unfair ways.

Hiring attorneys who know less about the claims process than you do isn’t the answer either. These same lawyers may have experience in ERISA litigation but who wants to have no benefit and a claim in court? Most people just want to be paid the benefits they are entitled to without giving up 40% of future benefits. You shouldn’t have to pay expensive attorney fees to have the blind leading the blind.

Insureds/claimants should make a real effort to understand the private disability insurance claims process. It’s not going to help you to allow your insurer to manage your claim when they are “staking the deck” against you with every activity.

You have to be smarter these days and one step ahead of the monsters.

 

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Everyone can probably recall at least one friend over the years who is a bit scary. You know, the friend who is quirky, moody, unpredictable, and just plain crazy. Even businesses theses days have their own idiosyncracies in process and attitude. And, although insurance companies have always maintained very high standards on the “crazy” ladders of inefficiency, one has to wonder how Unum as a company manages to exist.

I can well imagine Unum Life’s old CEO, Jim Orr III sadly shaking his head in disbelief as   Unum Life Insurance, previously  known as, “Lighthouse to the World” became “An Outhouse” of insurance bad faith in little more than a decade.

Reports continue to filter in regarding Unum’s negligent and inefficient claims process that is grossly untimely, managed by representatives who are rude, disrespectful and unkind. Repeated reports of Unum’s inability to handle STD claims in a timely fashion continue to be reported to me. Not only is Unum the company of “No”, it’s also joined the ranks of CIGNA, Aetna, and The Standard as bottom rung insurers who have difficulty working through their own claims processes.

What does this mean for Unum insureds and claimants?

  • Continued letters from Lucens asking for SSDI Authorizations even when you’ve previously notified you will not sign.
  • Rude phone exchanges in the form of “talking over you” and not giving you a chance to answer questions asked. (Most of you know I do not recommend speaking with Unum reps on the phone anyway.)
  • Allegations of not receiving paperwork with requests for the same information over and over again.
  • Claims reps not reading your file and trying to manage claims with limited or inaccurate information.
  • Using outdated technology internally to attempt to process approximately 500,000 new claims every year.
  • Internal strife — claims reps terminated due to age, sex and accusations of poor performance. Result? Constant new claims handlers, poorly trained and inexperienced.
  • Frequent harassing of physicians for more and more information.
  • Poorly trained claims handlers who are not trained in adjudicating ERISA vs. IDI claims.
  • Letters sloppily written, misspellings etc. Menu template paragraphs not deleted from letters to which the templates do not apply.
  • Gross untimeliness and violation of ERISA timelines.

There is enough evidence out there to suggest that Unum’s operating under a large backlog managed by claims reps who have no idea what they’re doing.

Despite the company’s poor public reputation and negligence, I spoke on the phone to an individual yesterday who told me, “I know my Unum claims handler. I don’t think she would do anything to hurt me! She’s been really nice!” Are you kidding me?

Let me be extremely blunt here. Unum’s claims handlers are trained to NOT tell you the truth, to question you in a way that provides information it can use against you, and is told time and again by management those who file claims are malingerers.

The entire time Unum reps are slapping your backs with gracious platitudes, they are internally  setting up “Primary Plan Directions” describing how they will work toward denying your claims. No one inside Unum is actually working for your general good to pay claims.

To think otherwise is actually, “the blind leading the blind” and is an extremely naive and pitiful position for insureds to take. Insurance companies do NOT work for your general good, nor do they plan to pay your claim long-term. The problem is that Unum now adds “crazy negligence” to the claims process contributing to an already complex and nerve wrecking claims process.

Does any of what I’m talking about sound familiar to you? Do you recognize Unum from your own personal experiences? If so, then you understand entirely the dilemma of Unum’s inability to manage claims in an organized timely fashion.

If it walks like a duck, swims like a duck, and quacks like a duck, it’s obviously a duck. In this case it’s a crazy Unum duck that can’t seem to get it’s ducks (pun intended) together to review claims fairly in a civilized way.

And, buying into the crazy won’t get you a paid claim.

 

 

 

 

 

 

 

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Once again I find myself answering questions from insureds such as, “Won’t my insurance company turn against me because I hired someone to help me?” “What will Unum do if they find out I hired you or an attorney? Won’t they deny my claim? “Will The Hartford be angry with me?” “I’m afraid to get help because I’m scared my insurer will hold it against me.”

My first thought when I hear to these comments is, “Well, here we go again.”

Although disability Plans and policies are legal contracts, very few people seem to want to defend them. Statistics taken from my own 25 year involvement with claims is that 60% or more ERISA Plan participants bother to obtain copies of their disability documents. I’m guessing around 10-15% of IDI insureds don’t have copies they purchased a long time ago. This isn’t good news either since most IDI policies contain FIO (Future Income Option) Riders with correspondence they may have wanted to keep in a safe place.

I find it astonishing that ERISA claimants often file initial applications and attempt to manage their own claims without ever reading copies of their Plans. I think it’s reasonable to assume that “one can’t defend what you don’t know.” Apparently, my blog has been somewhat helpful when claimants describe to me how they were asked to do a field interview and realized they needed to hunt down copies of their Plans. Usually, it takes some kind of a conflict in order to encourage ERISA folks to finally read, and  become familiar with, their group Plans.

I’m mentioning unfamiliarity with Plans and contracts because insurers take advantage of the fact that claimants are entering the process, unaware, naive, and unknowledgeable. Claimants will do anything, agree to anything, and say anything without thinking, in order to conform with what insurers are strategically requesting to deny claims.  The next claimant thought is, “If I hire someone to help me will the insurance company hate me and deny my claim?”

And, you are afraid of hiring an expert to help you defend what you don’t know?

First of all, insurers can only deny claims for two reasons, 1) you do not meet the eligibility requirements outlined in the policy such as Elimination Period, maximum hours worked, pre-existing conditions, not in an eligible class etc., and/or 2) you do not meet the definition of disability in your policy. While “unfair claims review” and “bad faith are at the root of denials, there are really only two reasons why claims can be denied.

Communications informing of claim denials must cite specific Plan or policy provisions and give reasons why you don’t meet the provisional conditions. New ERISA requirements require even greater disclosures about why claims are not paid.

At the risk of repeating myself again, let me also say that private disability insurers are only interested in the claim financial reserve values of claims and not claimants personally. Insurers do not have the time to “get huffy” and act punitive because claimants and insurers retain assistance.

No insurer cares whether you are “assisted” or not, but they do care about that $500,000 contribution to profit it will get when it denies your claim. Since less than 50% of ERISA claimants do not have copies of their Plans and are unaware of what to defend, they are, unfortunately, easy targets.

Those who are afraid of hiring assistance may not realize there are good reasons to do so. Some claims handlers tell me, “Thank goodness you’re on this claim Linda, I know I’ll get the paperwork I’m asking for right away,” Or, “Can you please tell your client I’m releasing his check because you’ve called me and let me know about the delay?” “I’ll get those forms out right away and send them to your fax.”

In my case, I’m trusted by the claims handlers to provide them with information when they need it! I also know many of the claims handlers and my name brings an element of trust and credibility to the claims management process.

I have to admit I do recommend extreme caution with attorneys who are, in my opinion, not great case managers. Attorneys know where their money is, and it isn’t in sending in update paperwork! In addition, some attorneys like to strong-arm the process that also leads to premature denials, but my major objection is that attorneys simply aren’t good private disability claims managers.

In today’s convoluted private disability world, it is more normal and customary to have assistance than not. Those who are fearful, stressed, and  paranoid about their claims are perhaps more destined to lose them than anyone hiring an expert who does know about Plan and policy provisions and who can help them defend their rights.

It doesn’t make sense to me to be so afraid of getting help while at the same time “punting” with your insurer because you haven’t obtained and read copies of your policies.

Taking a stab at claims management in the dark is far worse than retaining an expert to assist with the claims process in a professional way. There is a great deal to be gained by consulting with experts who are aware of the claims process and can make it work.

Claimants and insureds who are too afraid to defend their rights under their Plans or policies are those who will be facing claim denials in the future. Insurance companies aren’t stupid after all, and can easily identify the weakest links in the disability claim chain.

 

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Have you ever played a game of Texas hold’em when the deck has been stacked against you? If you have a private disability claim, you have sat at the table with players stacking the deck at every hand.

We now know that the claims review process is so convoluted and deliberately planned that at least 50% of those with private disability claims are denied benefits with a stacked deck.

The claims process for all insurers has been remade over and over again to perfect those strategies that are most successful in discrediting claims. Please find below the ways in which private disability insurers actually “stack the deck” against you.

Policies and ERISA Plans are flawed and unfair in the writing. It’s important not to miss this point. Before anyone actually purchases, or is eligible for group STD/LTD Group coverage, Plans and IDI policies are adverse to the general public. Private disability contains provisions such as changes in definition, mental health limitations and discretionary authority – loopholes to facilitate early terminations.

Liability decisions, present and future, are pre-determined before the claim is ever paid. Most insurance companies have an initial review process requiring claims handlers to determine “claim resolutions”, meaning how the claim will be denied in the future. Unum’s ERDs, documented for each claim within a “Primary Plan Direction” statement, dictates “next steps” in gathering documentation to legitimize the future claim denial.

In other words, insurers pre-determine the goal as denial, and then organizes the collection of documentation that creates the illusion that a denial decision is the right course of action. To this end, third-party facilities are retained to produce persuasive documentation, setting the company an arm’s length” away from medical decisions.

Those reading this post need to STOP and think about this for a moment. Whatever path your claim has been traveling on was pre-determined at the very beginning of your claim; and every action taken by insurers subsequently is to bring a “resolution” (denial) to a timely conclusion.

Even those claims paid for a long time are on a continuous path of pre-determination of what is needed to deny claims. Claims may be left in peace for a while, but whatever the “Primary Plan Direction” is, claims are manipulated and investigated toward that end.

The ultimate goal of setting Plan Directions is to allow managers to plan unit financial reserve profitability that is in line with company objectives. If managers know in advance what claims are planned to be denied, future profitability can be projected. The problem for claims handlers is that they are “pushed” to meet denial projections once planned and documented. Claims specialists who do not meet profitability goals are performance managed, placed on probation

IME Physicians are in the lingo loop. If I asked 5 insurance defense IME physicians to write reports on a fixed set of medical documentation, they would all use the same terminology and language in their reports. It’s as though they are all reading the same manual! It becomes increasingly apparent that IME physicians who’ve been in the business of IMEs for a long time learn what “lingo” to write in order to help insurers deny claims.

“Based on my review of the information provided there are no medical restrictions and limitations precluding this insured from returning to his/her sedentary occupation.” Or, “There is no objective evidence preventing this insured from returning to work full-time without restrictions.” And so on, and so on.

Unum’s old trick was to inform the IME physician of the amount of the insureds benefit. IME physicians were so indoctrinated into the process they knew immediately how important it was to write adverse reports, let’s say for benefits in excess of $4,000/month. The greater the benefit, the  more certain the outcome of the IME report would be in support of the insurer.


If disability insurance products are adversely written from the beginning, AND the outcome of claim applications are pre-determined, AND all internal and eternal reports are biased and prejudicial, AND ERISA Plans are allowed discretionary authority, how can you ever come to the conclusion that you’re sitting at a fair poker table with normal stakes?

The answer is quite simple – the deck is already stacked against you before the cards are dealt. My message in this post is to bring home the reality that there is no such thing as “fair and equitable review”, or even, “good faith and fair dealing.”

Denial and termination outcomes are dealt to you in the first hand even though you may be totally unaware that the cards are already stacked and the game is fixed.

 

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The Hartford is quickly rising to Unum Group levels of deceptive and dishonest claims management. Not only is the company denying legitimate payable claims, but employing MCN for medical reviews, over-the-top surveillance, in combination with deception and outright lying is the new “pattern of practice” breaking the backs of its claimants.

In a way, this doesn’t surprise me since The Hartford – Unum connection goes back to the old Duncanson & Holt Unum subsidiary management team who seem to use the same unfair practices learned from UnumProvident. What is recently revealed about Hartford, however, is its trend toward disinformation, or as some might say, outright lying, or deception concerning the status of claims.

While The Hartford’s claims process always was kept a “secret”, I don’t remember claims handlers making a real effort to be untruthful, going to the extent to communicate claims were approved only to deny claims several weeks later after extensive investigation results were received. Hartford’s 007 tactics of investigation are not truthful, and in my opinion, misrepresent every aspect of information submitted by claimants’ own qualified physicians.

The Hartford’s public reputation also suffers from what is aptly described as an “unfair claims process overburdened by excessive investigation.” Once a private insurer decides that every claimant is a malingerer attempting to defraud the company, the doors are opened to unfair claims practices that investigate all claims as though they were Al Capone.

Several years ago Ray Bourhis, the prominent attorney in the Hangartner case, told me, “Unum is now no better or worse than any other insurance company.” I disagree. In my opinion every other private insurer lowered their standards to Unum’s, including The Hartford. Private disability insurers are worse now than they ever were with no state regulators looking over their shoulders.

Use of third-party medical reviewers is causing a chit storm across the entire spectrum of private claim review. As a result ERISA claimants are having to suffer the fallout of extreme fraud and investigative paranoia, losing valuable benefits depended upon for financial security.

In my opinion, The Hartford is now second to Unum on the line-up of egregious disability claim review companies. Employers should use extreme caution when spending costly budget dollars on benefits employees will never see.

All insurers are expected to engage in “good faith and fair dealing” review, but unfortunately insurer profits are not derived from “fair and equitable” review. Instead, insurers are now engaging in deceptive claims practices where telling lies through misrepresentation is more profitable.

In my opinion, The Hartford is now second only to Unum Group in deceptive claims practices. The company finally reached the bottom of the egregious barrel, a reputation that is documented all over the Internet.

I would not want to pay The Hartford’s legal bills in the coming months.


DCS is a national consulting organization that provides expert claims management services to those with private insurance. I offer free initial consultation.  Please contact me about how you can become a client.

If you need assistance with your disability claim please feel free to give me a call..

If you are interested in becoming a DCS client, please feel free to visit my website at: http://www.disabilityclaimssolutions.com

  • Telephone: (207) 793-4593
  • Fax: (207) 274-2331

Detailed information about DCS, Inc. can also be viewed on this blog by clicking the “Consulting Services” Tab from the Lindanee’s Blog Home Page. You do not need to go through the complicated maze of disability claim management alone. I am here to help.

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