Archive for the ‘Claims Process’ Category

Have you ever wondered why Unum Group always seems to be 13 eggs short of a dozen?

Documentation lost, late letters, wrong templates used in letters that don’t pertain to insureds, failure to read the files, and on and on. What used to be a well-known characteristic of CIGNA and Aetna, both bottom feeders by my standards, has quickly become the sign post for Unum Customer Service.

Neither Unum Life nor UnumProvident lacked good customer service since management pushed an “Exceeds” standard upon its claims handlers. In fact, management once said at a company meeting, “We want most customers to say they don’t agree with our denial decision, but they understand why we did it.”

Well, that might a bit far-fetched, but Unum’s management actually believed they could convince their insureds the company did the right thing by denying their claims. Unum Life wasn’t successful, by the way, they were taken over by the Provident companies in 1999.

Today, Unum’s lack of competence obviously comes from untrained claims handlers who are deliberately “dumbed-down” to not know anything. It’s very hard to keep employees dumb while at the same time expecting they know how to adjudicate contracts. Inside sources tell me new employees are trained to presume everyone is malingering and to apply the lion’s share of risk management activity.

Remember the conversation my investigators found on a Unum manager’s Facebook page? “Insureds are like Slinky’s, they aren’t worth very much, but you like to see them tumble-down the stairs every now and then.” In my opinion, this has been the philosophy of Unum claims handlers for quite some time – not exactly fair and equitable claim review is it?

It also occurs to me that something could be remiss with Unum’s data center in Columbia, SC where all of the mail is received and processed. It could also be that the “frequent firings” have downsized staff to the point of not being able to handle Unum’s business.

Whatever the reason, in my opinion, Unum isn’t functioning very well. If you are a Unum insured and have found that communicating with the company is like trying to nail Jello to a tree, then you know what I’m talking about. Unum is a prime example of how a company can go from a “Lighthouse” (Unum Life’s logo) to an “Out House” in little more than a decade.

Incompetence is clearly annoying, but has become the standard for processing a Unum disability claim.


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This past week DCS, Inc. received several calls from avid readers of the Blog requesting assistance. Unfortunately, after talking with them I discovered their claims had recently been denied.

One of the most frequent topics I address on Lindanee’s Blog is the need for prevention of denials rather than having to deal with the risk of an appeal after the fact. DCS, Inc. is entirely about preemptive action and prevention of denials. This is not to say that I guarantee successful claims, but it does mean that having a claims expert on board to assist, particularly someone with direct claims experience does make a difference.

Once an ERISA or IDI private disability claim is denied insureds basically have two choices: 1) do the appeal yourself, which I do not recommend, or 2) attempt to find an experienced attorney who is willing to take your case – a very expensive option.

There are many things that can be done to place medical, occupational, and financial information in Administrative Records (ERISA), or claim files (IDI) that support disability. I can’t tell you all of them here because this information is proprietary to me and DCS, Inc. and represents a total strategy that consistently produces a 98% success rate.

Please give some thought to the benefit of assistance vs. claim denial. I would like to help, but you really need to contact me before your claim is denied, not after.


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Since we’re coming up on 1st Qtr. results I thought I would create a new category called “Unum Targets” and talk about what is meant by “targets” and how Unum uses a target to make money. Since I’ve had several RNs contact me, I thought I would begin with that occupation.

The occupation of Registered Nurse (LPNs also) has always been an easy hit for Unum’s occupational analysis. Most RNs are participants in employer ERISA Plans which also makes it easy for Unum to “do its own thing”, twisting and interpreting “occupations” to deny claims at the change in definition after 24 months.

As with all things at Unum, “a target” usually begins with a financial reserve high enough to warrant the lion’s share of investigation, which is generally not a problem for the occupational category of Registered Nurse. Moreover, there is biased presumption at Unum that once someone earns an RN license he/she can perform every aspect of medical care from school nurse to hospital administrator.

Specialty RNs recognize this as all bunk, but Unum continues to sell the idea that RNs are multi-purpose professionals who are able to instantly transform their credentials and experience into other medical roles they aren’t qualified to perform. I think we can all agree that an ER RN, or a Pediatric ICU RN cannot instantly get a job as a school nurse or hospital administrator. Medical specialties are not a “one size fit all” occupational opportunity.

Still, Unum continues to sell the idea, particularly during any occupation investigations, that once an RN, always an RN who can work in any other nursing field, and immediately be qualified to “get other jobs.” Why would anyone suggest that a Nurse Anesthetist could work in RN patient care, or in family practice with a doctor? Or, vice versa.

Unum also gets away with this kind of strategy because state and federal regulators, who are not medically trained, are not aware of the disparity among medical nursing specialties and training. However, RNs will tell you there is a big difference between ER nursing, and providing patient care on the floor.

Unum always seems to over use the occupation of school nurse and often documents how RNs in other specialties can cross over to this career path. This isn’t true at all since a school nurse must also be trained in educational state laws, and be trained in what the restraints of caring for children in the educational system are. Medically caring for students while in school is not an easy cross over for most RNs assuming Superintendents would even hire them without additional training.

As with all things at Unum it is always the shortest profitability distance between two points. When I worked for UnumProvident some time ago now, there was always an unwritten presumption that RN claims would be denied after the any occupation investigation. Justification? The career of a Registered Nurse is overly broad and anyone who is an RN can easily transition to another medical career field. Just ask an RN how possible that really is.

It’s important to note in these new discussions of “targets” that we are really discussing unfair claims practices. Let me define what a “target” really is.

Insurance targeting involves the following: (This is my definition although I’m sure there are others.)

“The biased separation by any insurer of disability claims into categories, occupations, impairments, SSDI status, and financial reserve high values, for the planned objective of obtaining what appears to be credible documentation in support of not paying claims.”

Notice that the targeting of claims takes place first, a File Plan is then devised to outline how to go about obtaining proof that the initial identified objective of denying claims was the right decision to make. First, claims handlers set the objective to DENY, and then they provide the documentation to prove it. This is targeting in its truest form.

Registered Nurses are targeted within Unum’s internal review procedure because Unum is able to deny claims with a TSA (Transferable Skills Analysis) alleging RNs can work in medical jobs for which they have no real training.

The strategy is profitable and Unum has no reason to stop the unrealistic career transitions it uses to deny claims.







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Unum has a unique paranoia when it comes to insureds who hold valid real estate licenses. Regardless of the insured’s own occupation, just having a valid real estate license sends Unum into a frenzy of investigation assuming license = unreported earnings.

The problem seems to stem from the fact that in order to have a valid real estate license an agent must be affiliated with a particular broker. It’s the same with insurance producer’s licenses in that you must be approved to sell insurance through one or more companies before you can have the license.

Unum finds out about the real estate licenses by searching on the internet. There are programs out there that allow investigators to search for licensees in just about every career field. If you hold a valid license, Unum knows about it.

As an example let use the claim of a Martha Smith (not real name) who worked for UPS as a Scan Specialist but has been on claim with Unum for the last 10 years. Years ago, Martha obtained her real estate license and associated herself with the “Countryside Real Estate Agency in her area. When Martha became disabled and could not return to work with UPS, she kept up her real estate license “just in case” she was able to work in that field in the future.

When Unum found out about her active real estate license from the internet the “..it” hit the fan at Unum. Martha was required to provide 10 years of tax returns, lists of management properties, W-2’s, 1099’s etc. when in fact she had not worked and had no earnings to report. It took more than a year and a statement from the broker that Martha was not selling property to convince Unum it made a mistake.

In another incidence Ralph went out on disability and had been on claim for nearly 18 years. His wife ran a real estate agency and Ralph maintained his real estate license even though prior to his disability he was a retail store manager. Unum immediately requested all of the business tax returns for the real estate agency even though Ralph’s wife is not a party to his disability contract. Ralph’s wife is under no obligation, by the way, to provide Unum with anything pertaining to her business of which she is a 100% owner.

In some of the more complicated license situations Unum actually accused an insured of laundering money through his wife’s business. There doesn’t seem to be an  “off switch” to Unum’s paranoia concerning active real estate licenses. And, the administrative hassle Unum puts insureds through for nothing is an unfair claims practice.

In my experience, most people who have licenses want to keep them active and real estate is no different from any other license. However, I’ve always encountered situations with Unum when there is an immediately presumption that if an insured has a real estate license, they are selling real estate and not reporting the income.

Finally, insurance companies presume active licenses are indicators insureds will be returning to work in the future. Uncertain whether insureds will be honest enough to report the income, insurers become paranoid that they have in fact “missed the mark” in locating unreported income.

Insureds who keep their licenses active should be aware of what’s possible from a crazed company who has more money and time than management common sense.


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First Lucens – Now GENEX

For the past year, a company called Lucens has been chasing Unum’s SSDI financial information in order to recalculate claims in hopes of finding nickels and dimes of unpaid overpayments.

Well, it looks as though Lucens didn’t last all that long, at least on Unum’s SSDI requests. Claimants are now reporting requests to obtain claimant SSDI financial data  are from GENEX, Unum’s old on-again, off-again SSDI partner. It’s unclear whether Lucens is sticking around to deal with Unum’s settlements, I seem to think they might be.

DCS, Inc. has received several calls this week from claimants confused with the request to sign an SSDI Authorization from GENEX with a supposedly Lucens created form. Claimants are themselves questioning where the Authorizations are coming from even though the form is deceptively designed to look like an SSA-form.

Actually, Unum’s claims process seems to be somewhere between, “I don’t know….let’s request it again…and let’s not read the files.”  Even though Unum Life Insurance engaged in unfair targeting, at least the former company supported “exceeds” customer service and strict organization of the claims process.

Unum group actually turns their claims employees into village idiots (sorry) and then sends them to Disneyland to “Aspire” to be great. Go figure! In reality though, Unum insureds and claimants seem to feel more confused and frustrated with the claims process than ever.

Today, it’s hard to work for Unum insureds and claimants when the Unum agenda includes claims handlers who have no idea what they are doing. It appears as though the administrative personnel are just pushing around paper which doesn’t do much to help Unum’s claim back logs.

How many of you have received recent letters from Unum requesting nothing, but simply informing you, and apparently it, that both parties have the right to request an IME? Or, letters from Lucens – no wait – GENEX, asking for SSDI financial records? Or, a questionnaire that seems to come out of the blue? Finally, a “second request notice” for information you faxed yesterday.

In my opinion, Unum lost control of the claims process and it shows. What’s next? In any event, GENEX is now the company who is sending out SSDI Authorization requests and my recommendations remain the same. (Please see prior posts.)

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Are you finding it irritating that your Unum claims handlers keep asking for the same information over and over again? You just sent in your SSDI approval letter and once again your claims rep is asking for it again? What’s going on? How many times should you be expected to send in the same information over and over again?

Unfortunately, your Unum rep is not reading your file and probably doesn’t know what’s in it! Or, Unum is so paranoid about their Lucens SSDI initiative that management is forcing the U-numbies to request it again. Either way, it becomes damned irritating to have to fax the same information today you just faxed yesterday!

Unum doesn’t have paper files anymore but uploads everything electronically that is readable by claims handlers on their screens. To be honest, this process drove me crazy and crosses your eyes after a while looking at one, and maybe two lit computer screens at the same time. It doesn’t surprise me at all that Unum’s bottom administrative reviewers are avoiding reading the files.

Why Unum management doesn’t take more of a role in making sure its claims handlers read the files is surprising. Requesting the same information over and over again isn’t cost-effective for the company and is extremely irritating to insureds and claimants. At least at Unum Life Insurance we were expected to read the files and be familiar with claims enough to know what’s in them.

My suggestion to insureds who are asked to submit the same paperwork over and over again is to send a fax reminding the claims handler that you have a confirmation of fax receipt that it was previously sent. You can politely say, “May I suggest that you check the file?” You shouldn’t just rush to fax the information again until such time as the claims handler has had an opportunity TO READ THE FILE.

Unum claims handlers are quickly becoming the new negligent, uninformed group of the insurance world. Whatever happened to the expectation that claims handlers should KNOW the file before trying to manage it?






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IDI insureds are victims to policy misrepresentations concerning definitions of Prior Monthly Income (PMI) as well as contract provisions containing language that prevents business losses arising from sources other than medical disability.

PMI is a very important dollar figure used in the calculation of “Residual Disability”. In fact it is a fixed amount determined in a manner specified in the policy, usually from several years of prior tax returns.

It is accurate to say that in certain policies issued by Guardian an other that business losses claimed on Tax Returns and Profit and Loss Statements must be due to medical disability. Prior business losses that are discarded as NOT due to disability include:

  • Losses from changes in accounting method.
  • Losses due from economic recessions and poor investments.
  • Loss of business due to competition or new geographical changes.
  • Losses due to labor shortages.
  • Loss of qualified personnel other than yourself.
  • Losses due to changes in healthcare, HMO, PPO fixed procedure changes. Medicare rulings.
  • Losses leading to bankruptcy, or other legal filings.

In short, business losses due to medical disability include the following:

  • Loss of business or clients due to the fact that you can no longer be present, or administratively run the business because of medical impairments.
  • Loss of goodwill and business clients subsequent to your physician recommending that you stop working.
  • Your disability keeps you from spending the same amount of time, or engaging in the same material and substantial duties that you did prior to your disability.
  • You are able to show a history of income losses and loss of business because you are unable to do the same job tasks due to medical restrictions and limitations.

I think you get the idea, but let’s be clear – these definitions in IDI contracts are written in connection with the calculation of PMI and are not mentioned for continuing disability. It makes sense to me that all losses after an individual is disabled are due to medical disability and the inability to perform one’s pre-disability job.

However, companies such as The Guardian, Mass Mutual and MetLife are throwing out losses at their discretion subsequent to disability for “non-disability related reasons.” This strategy reduces the amount of “Residual” benefits paid to IDI policyholders and if the contract provisions are examined carefully, a distinction is drawn between calculation of PMI and calculation of the current month’s benefit.

The malfeasance of the calculations of PMI and the requirement of “…must stem from medical disability” provisions are often ignored or missed by IDI insureds. You can be sure that insurers are misrepresenting policy provisions in order to reduce benefit payments, and they are doing it deliberately.

On those occasions when “throwing out losses” produces a $0 or low benefit, insurers will generally entice complacency by paying insureds 50% of benefit, as a gesture of good faith – an action that is also a breach of contract. Insureds’ thinking that “something is better than nothing” better look again at their policies.

I can understand that non-medical business losses shouldn’t be used in the calculation of past income, or PMI. For example, assume a business with significant losses due to change in accounting method. If this were allowed, everyone would change their accounting method just prior to filing for disability. I get it….

However, throwing out business losses subsequent to an approved disability claim (where no contract provisions exist) is an egregious and unfair business practice that reduces benefits paid (and reduces financial reserve).

Throwing in the 50% of benefit as appeasement to insureds just adds to the bad faith methodology of engaging in breach of contract. I find that more and more IDI insurers are depriving insureds of benefits due to out of contract misrepresentations distinguishing between prior PMI calculations, and losses due to disability after claims are approved.

This is an area where IDI insureds should sit up and take notice, particularly when offered 50% of benefit in lieu of adjudicating the policy in accordance with actual provisions. These tactics are breaches of contract that should not be accepted.





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