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Archive for the ‘Claims Process’ Category

One of the things I hear most often from insureds and claimants is that they spoke with insurance representatives on the phone and suddenly they either begin to receive outlandish requests for information or their claims are denied.

Although I’ve been writing and posting for years that it’s not a good idea to speak with insurance reps on the phone, many people still take the risk of doing just that. Insureds are either so scared they think they have to, or sincerely believe if they don’t their claims won’t get paid. Neither one of these are true.

In the interest of trying to explain [again] why it’s not a good idea to speak with insurance reps on the phone, please note the following:

  • Insurance reps are trained to document what you say through “filtered listening” techniques. Anything you say to reps is not documented the way it is said, but is “translated” in adverse ways.  Insurance reps can never “tell a straight story” and aren’t encouraged by management to do so either.
  • If disability insurance were any other kind of business insureds would be falling over themselves to get “it” in writing. All insureds should request to have all communications in writing so that they will have a permanent written record of all of their dealings with the insurance company.
  • Today, insurance reps like to speak to insureds to obtain additional family and social information that can be used by investigators to “hunt down” children and “friends” from Facebook. I’m seeing more and more denial letters containing information from Facebook “friends” about descriptions about outings and other activities.
  • Attitudes of, “I have nothing to hide” often encourages insureds to share more information than is necessary to investigate any disability claim. Not having anything to hide is NOT the point, and it won’t stop insurers from “interpreting information in their own favor.” This is also true of surveillance when insureds are cavalier and say, “I have nothing to hide.” Once you are observed engaging in activity with “nothing to hide” it quickly turns into “work capacity”. Please remember this.
  • Claims handlers can’t harass or abuse you in written letters that become part of the record. If you have a rude claims rep why do you spend the effort to listen to that kind of exchange? You won’t be abused verbally if you insist on everything in writing.
  • Anyone taking opiate or other pain or depression medications should not be speaking to any insurance reps on the phone. In my opinion, those taking certain medications are not able to respond accurately to questions asked simultaneously. At least responding in writing allows insureds to actually “think” about what their responses should be. Claims handlers know “you’re fuzzy” and take advantage.
  • Although my impression is that most insurers are NOT recording conversations, some still do. If you are unaware and say something detrimental to your claim, it can be discoverable in a court of law. Written communications are a matter of record and pretty much say themselves.
  • Claims handlers are given standard templates of information to ask about you, your activities and family. Much of the information is subject to interpretation and can be used against you. How many times have you said to your claims handler, “I never said that”, or, “that’s not what I meant?” What you actually said is never documented.
  • Insurance companies cannot use against you what you do not say.
  • Once something is said to an insurance company, you can’t take it back.

Another way of getting your goose cooked is to have an Internet presence. Recommendations to insureds and claimants – No Facebook, no LinkedIn, no Twitter, no website leftovers – nothing. The whole purpose to Facebook is “socializing” and the worst thing you can do is communicate and share photos and give the insurance company names of your friends, children and family.

Let’s not underestimate the hackers, they can get into any Internet media and use information against you. In fact, many insurers of auto and life insurance also hack social media for underwriting information. Insureds and claimants need to be “off the Net” entirely for the period of time benefits are payable.

Stay away from emails and insurance website portals. Emails are not a good way to communicate. Some insurers do not allow communication by email, others encourage it. The problem with emails is that they may or may not be added to the official record. Insurance website portals have tracking software attached to it that tracks insureds all over the Internet.

Although I’ve been writing articles about communications with insurance companies for many years, not everyone adopts my best practice suggestions and continues to speak with insurers on the phone. I really don’t know how I can more clearly communicate the dangers of verbally communicating with reps who do not accurately report what you say other than provide you with the above information. The above are “best practices” in claims management from the perspective of insureds and claimants.

If you are looking to cook a goose today, please make sure it is not your own disability claim. There are many ways for insurers to use your own words and statements against you. I recommend all communications in writing in order to accumulate a complete written record of all dealings with any insurance company.

Please feel free to give me a call to find out how DCS, Inc. assists insureds and claimants with managing communications with insurers.

 

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Judging from the number of calls and emails I receive it’s clear those in the insurance industry are wondering what Unum is up to that is producing the amount of negligence and chaos now present in the company’s claims review process.

Unum’s unfair claims practices are no longer a matter of supposition but are obvious to those who have dealings with the company. Suspending benefits for no reason, rude and disrespectful claims handlers, continued firings of employees, removing internal departments and then cloaking that fact from other employees, outsourcing large amounts of work to third-party facilities or overseas, attempting to allege large overpayments are owed, using the settlement department (or Lucens) to unleash claim investigations, and finally terminating claims previously paid for long periods of time, 10, 15, even 21 years.

From what experts are seeing currently Unum now has three initiatives in operation to attempt to either deny more claims or reduce benefits to $0 to avoid payment of benefits that are legitimately due.

  1. Claim referrals to Lucens to obtain SSDI financial information that can be used to recalculate benefits and offsets for the purpose of conjuring large overpayments due and reduction of benefit amounts payable to $0.
  2. Using the settlement department (and, it is unclear whether Unum has also transferred this function to Lucens) to engage in extensive claim investigations also for the purpose of denying claims rather than settling them. Obviously, it’s cheaper for Unum to deny rather than settle claims.
  3. Reclassifying previously paid physical claims into mental and nervous impairments so that claims can be denied immediately or paid for only 24 months. Unum’s frequent requests to obtain SSDI Form 831 information and psychotherapy notes is for this purpose.

Unum’s insureds and claimants should consider that the company’s new initiatives are “deliberate” and have been engaged in enough to satisfy the definition of “pattern of practice.” DCS, Inc., in cooperation with litigating attorneys has been dealing with the issue of Unum attempting to collect on large “re-calculated” overpayments.

In my opinion, any insurance company (or its agents) that deliberately twist, or misuse generally accepted accounting principles and the concept of “continuity” to harm those it does business with is fraud, clear and simple. I know that there are many insureds and claimants who are receiving “letters from Lucens” and have no idea what to do with them. Others who have asked Unum for settlements are now in the midst of extensive investigations.

Simply put, it now appears that Unum is targeting claims to obtain all information relevant to “offsets” and is forwarding that information to Lucens for financial scrutiny. If this is incorrect, I’m sure the Internet snoops who forward information to Lucens will contact me as they have in the past. However, on the face of it, it does appear that Lucens is connected to Unum’s new target initiatives, and is either chasing the information and forwarding it to Unum, or is further involved in actually assisting with the new “re-calculations.”

Between 2001-2004 UnumProvident was severely criticized and reprimanded in the California Settlement Agreement not to abuse the Mental and Nervous provisions in its policies. The company agreed to change its claims practices and not back date 24 month limitations, but it appears Unum is once again abusing mental and nervous limitations by demanding the release of actual psychotherapy notes, especially for claims paid for long periods of time.

Psychologists and psychiatrists have long come to the conclusion that actual therapy notes are proprietary and are not written for the purpose of determining disability. Most mental health providers do NOT release actual psychotherapy notes and prefer to support disability in summary form (filling out forms and questionnaires.)

Apparently, therapists and mental health providers have rightfully come to the conclusion that disability insurers misrepresent information contained in psychotherapy notes and refuse to release records. Unum’s current requests for mental health records may prove not to be as profitable as they think.

Nevertheless, Unum is once again abusing the Mental and Nervous provisions in its policies. What is not surprising is that Unum’s bold steps to engage in “patterns of practice” adverse to insureds are obvious, open and deceptively arrogant.

Insureds and claimants should be aware of Unum’s tactics to engage in claims practices that are unfair, and in at least one case (M&N issues) has been determined to be egregious by the California Settlement Agreement.

If you have any questions about Unum’s target initiatives  to harm you and your claim, please feel free to contact me. We are already assisting clients who are now dealing with Unum’s unreasonable requests.

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As a former Lead Benefit Specialist with both Unum Life and UnumProvident I’ve seen thousands of communications from claimants from every major US disability insurer. During those conversations I have been called quite a few names – some good, and some very bad. Learning what to say and not say to insurers who are looking to deny claims is a learning process and takes time.

Here are a few “tips” if you are managing your claim on your own. DCS, Inc.’s clients are not recommended to speak with any insurer on the phone, but if you take the risk and do it anyway, please pay attention.

Be brief. Anytime a claim is filed with a disability insurer, the claims handlers will attempt to interview you by phone. Unum, for example, is required to contact you for such an interview within 3-5 days of assigning your claim to a claims examiner. There is a template list of questions approved by management, and all claims handlers are trained to plan the communication in such a way to encourage you to provide information about yourself and your family.

In today’s technological terms, family member names and other information are like “gold” to insurance companies. From the data provided by you they are able to locate family Facebook sites and obtain additional information about your activities. I do not recommend participation in any social media if you are receiving disability claim benefits.

You will also be asked “What happened?” “Name your treating physicians.” “What are your prescribed medications?” “What other income do you have?” “Have you applied for SSDI, Worker’s Comp etc.?” And so on. Of course, insureds should always answer questions honestly but do not elaborate. Don’t offer any explanations beyond what is being asked. Answer only what is asked and stop. I know that’s extremely hard, since your first instinct is to want the claims examiner to believe you. Remember, the claims examiner’s agenda is to close your claim if they can. Toward that end, everything you say can be used against you. Answer only the questions asked, then stop talking. Remember, DCS, Inc. does not recommend speaking with any insurance company on the phone.

Resist the temptation to tell the story of your life. I am reminded of one scenario in particular that happened so often in the Unum claims department.

The claims handler calls the insured for the initial interview and the claimant begins to speak in what seems like an endless story of his/her life. In that conversation, he says “It’s going to be hard for me because my wife was just diagnosed with leukemia.” Well, its likely Unum will say you filed a disability claim because you want to take care of your wife. Anything not directly related to your impairment should not be discussed with your insurer. Remember, an insurance company cannot hold against you what you do not say.

Here’s another example, “ My wife is working, so I’m taking care of my kids.” Or “ I’m taking care of my grandchildren.” I cannot stress enough how often that kind of information is held against insureds.  In addition, DO NOT WRITE LONG LETTERS TO Unum or any other disability insurer. The assumption is, if you can type or write long 10-15 page letters, you can work. Resist the temptation to send any communication more than 1 page to Unum. You are not obligated to tell the insurance company anything that is not directly related to your insurance policy and your impairment. No family information should be given and nothing not addressed in your policy should be discussed.

ABC – “Always Be Cool. As I mentioned in the intro to this article, I have been called everything although my favorite was “Attila the Hun.” I’ve listened to profanity, anger, tears, frustration, threats, desperation, phone slams, you name it, and if you can think it, I’ve probably been called it. The truth is, though, the claims handler knows something you don’t. When you lose your cool, Unum’s in control and you aren’t. Please don’t ever let an insurance company control you or your claim.

Since everything is documented, anything you say, and the manner in which you say it, will be held against you. Disability insurance companies are not concerned with what you say, or, call them. They just want your claim to go away.

Insurers generally are only concerned in using what you say as a reason to peg you as a “nut” and support your claim for denial. Whenever you feel like calling the claims examiner names, or telling Unum to “stuff it,” go into a closet let it all out, then write a short, polite letter discussing only the facts of your claim, limited to one page, making sure to keep a copy. You are talking to an insurance company who does not care what you call them; they don’t care what you think; and, clearly they don’t care if you get paid or not.

Never download medical information from the Internet and send it in. Why not? Unum doesn’t care. They won’t read it. It may get pitched. It will be used against you. If Unum has made a decision to disregard the opinions of your primary care physician, why would they care about medical information YOU downloaded from the Internet about your impairment? Technically, if you send it in, it is supposed to be a part of the Administrative Record (your claim file). I had an attorney from Unum’s legal department tell me once “All this downloaded information means is that the claimant’s attorney knows how to use the Internet and save PDF documents.”

Unum is scanning and imaging all paper now in Chattanooga, so it would be interesting to see just how much of  downloaded “stuff” from the Internet is actually scanned on the permanent record. (Image) When it was an “all paper claim” most of this information “hit the can.” If your occupation was as a Secretary, for example, sitting at a computer, downloading, and printing a lot of paperwork to send to Unum could be interpreted as work capacity. Don’t bother, no insurance company cares how much you can download from the Internet.

Maintain a journal. Getting angry will not serve you well when dealing with any disability insurer. Make sure you start a journal or diary and keep records of all conversations you have with Unum or any other company. Ask for names of Consultants, Managers, Directors, Vocational and Medical reviewers and document the substance of every conversation and call you have and receive from your disability insurer. Sometimes the claims examiners are not professional with you, so make sure you document those conversations as well.

Document, document, document. DCS, Inc. uses Evernote to document all activities on client claims. You should do the same if you are managing your disability claim alone.


I know it is difficult enough trying to get a disability claim paid these days. It’s a frustrating process. But, name calling, accusations, anger and profanity just come back to haunt you in the end. Some insurers even questions whether or not insureds should be in counseling because of the way they behave when speaking with the insurance company.

Engaging in such conversation gives the insurance company control over you and your claim. Don’t give them that kind of power. DCS, Inc. clients have a much easier road in this regard since they have the expert help needed to navigate the system safely.

 

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Recently, it came to my attention that The Standard outsources medical records requests to a company called Release Point. Despite the fact that all ERISA Plans give claimants 30-45 days to submit proof of claim, this company is calling treating physicians and threatening to terminate the claims of patients if medical records are not submitted in (5) days.

When I contacted The Standard claims rep she did not know of the practice and basically said, “We’ve never heard of that complaint before.” Although the rep admitted that the (5) day deadline to submit paperwork was out-of-contract, it’s unlikely anything will be done to stop Release Point from making threats. Claims handlers simply do not have the clout to instruct an outsourced agency of what they should and should not do.

The purpose of this post is to also communicate that when the insured was contacted by her physician’s office staff and told of the deadline she went into a panic. “They are going to try to deny my claim….my doctor may not be able to get the information on time…how can they do this to me now?” The phone call also took place around 3 p.m. on a Friday afternoon so you can imagine what the claimant went through over the weekend.

To begin, ERISA Plans are very explicit about timelines. Plans most often contain provisions requiring claimants to submit information at their own expense within 30-45 days of the date of the letter requesting the information. This deadline also applies to claimants’ treating physicians.

No insurance company can deny an ERISA claim out-of-contract for failure to provide patient proof of claim within (5) days. To be clear, I’m assuming the (5) day request was the only one that was made. If The Standard had previously requested patient records in 30 days, but failed to receive them, AND THEN gave 5 more days, it might be more reasonable although in my opinion the request for records should be tolled another 30 days.

Remember my recommendation that all claimants read their policies and understand the provisions? Had the claimant remembered her policy timeline of 30 days perhaps she could have made the following response to her doctor’s very panicked office manager, “No, this is just a threat, my benefits cannot be denied unless I am over 30 days. Please fax me the information The Standard is requesting and I will provide it to them myself.” I think everyone would have been a bit calmer and less threatened.

I do understand the impact of insurance threats though and the emotional damage they do. For the last 25 years I’ve been writing that “knowledge is power” when it comes to disability claims, but when the “fire bell in the night” occurs, it’s hard to think on your feet. I get that entirely.

Please remember that all ERISA Plans allow 30-45 days to provide proof of claims. IDI claims allow 90 days after the end of a month in which disability is claimed. Think about this when your unethical insurer or its outsourced facility decides to strong-arm you, or your physician, for medical records.

 

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What happens when a really awful disability insurer such as Unum Group engages in new strategies to deny more and more claims?

Recent information received from inside sources indicates Unum recently fired older workers and is training new, younger Specialists to assume all insureds and claimants who submit claims are doing so for secondary gain.

Vilifying insureds and claimants always was a Unum specialty so it does not surprise me that the company is once again (or still) focusing on new claim propaganda training. Years ago I described the training as “brainwashing” and clearly new Unum claims reps will be forced to do what management tells them to do rather than what’s written in policy contracts.

Most Unum employees won’t ever realize the disparity between how disability claims should be reviewed versus how they are actually viewing them. All employees are forced to participate in a claims review process that is unfair and harassing, but know clearly, “it’s Unum’s way, or the highway.” Employees who want to keep their jobs do what they are told and remain faithful to the Unum collective for a paycheck.

Word is that Unum management is also quietly doing away with entire work groups and sending internal departments overseas. I’m also told that internally Unum is masking the disappearance of work groups to give the impression they are still on campus. Why the deception?

What this means for insureds is that Unum’s reps will be managing claims in “high aggressive mode” assuming everyone is dishonest until proven otherwise. Inside resources have also suggested the “training” includes reviewing medical information with “focused selection” (my term) to interpret medical information in ways that are favorable to Unum. In my opinion, Unum Group has always engaged in false medical review evaluation so it’s hard to imagine the process getting worse.

Those with Unum disability claims will need to pay particular attention to differences between what’s true and what isn’t and swiftly take the necessary actions to correct the official record.

Also, as I indicated in my prior post, social media and Internet presence is out of the question. Unum’s website portal should also never be used.

It really is too bad, but inside reports about Unum are never good news. No wonder my resources describe Unum as, “same sleaze, different day.”

 

 

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Insurance claims handlers are taking their good ol’ PTO time leaving insureds and claimants with unanswered issues and resolutions during the summer months. It’s not as though companies like Unum, The Hartford, and MassMutual can’t figure out how to replace vacationing claims specialists, but it sure looks like claimants are at the bottom of the priority list during the summer months.

Out of the office claims specialists are directed to turn their claim blocks over to a “buddy”, or someone else in their respective units. However, getting through for help is still a chore for insureds who contact insurers by phone. (As you know, contacting insurance companies by phone is not recommended.)

Making matters worse are claims handlers who leave on vacation without manually approving benefits on their pay systems. Insureds and claimants are left without monthly benefit payments until their reps return to work.

“Who’s watching the store?”, you might ask. Good question. Years ago so many Unum reps went out on vacation at the same time that Tim Arnold had to put his foot down and say, “No” to unlimited summer vacations. In my opinion, some one needs to do that again.

It’s beyond me that insurance companies can’t figure this out and still provide good customer service during the summer months. Worse yet, insurers aren’t providing adequate customer service at any other time of the year either. Like all corporations these days, customer service is a thing of past unless it’s coming from India or another non-English speaking country.

Insureds are recommended to ask for Customer Service or claims managers when claims handlers aren’t to be found. At some point, some one has to show up and answer the phones.

 

 

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Most employees who are covered under an employer’s group ERISA disability Plan are unfamiliar with Plan provisions and what the Plans actually provide versus what they take away. While employers have a way of selling their benefit packages as “free disability coverage”, an examination of the details point to a very different product.

To begin, Employer ERISA Plans have more adverse provisions than they have favorable ones. Group insurer Plans are formulated to give insurers an interest in not paying claims. Think about it….the same insurer who pays claims also makes decisions as to whether claims should be paid at all. In combination with the fact that profit is realized by NOT paying claims, from claimants’ perspectives, the risk of not getting paid at all is pretty high.

In addition, employer Plans contain adverse provisions from the beginning….24 month own occupation and mental health limitations, limitations for payable benefits as a percentage of pre-disability income, offset or reductions in benefits provisions, restrictions on time limits for providing “proof of claim”, and maximum duration limitations. In addition, ERISA Plans have a federal jurisdiction that excludes bad faith litigation in state courts.

On top of the written failed contractual product, the federal government allows “discretionary authority” giving insurers sole authority to adjudicate the Plan and decide for itself who gets paid and who doesn’t. As if the deck wasn’t stacked enough before, discretionary authority seals the deal to insurance corporate profitability at the employee’s expense.

After the fact, when claims are denied, attorneys often contribute to the problem by charging fees to maximum duration that reduce benefits received to less than 30% of pre-disability earnings. That is, if claimants can find an attorney who will take an ERISA case at all.

What is unfortunate is that claimants often depend on their Employer’s Plan for sole income during periods of disability. While ill, employees are forced into an administrative nightmare of constant paperwork, phone calls, and various requests that often worsen medical conditions, such as stress, anxiety and pain. Claimants are forced to deal with insurance companies, that only care about meeting financial objectives within a certain time period.

Employer provided group disability insurance should never be relied upon long-term to meet 100% of financial needs. It can be terminated instantaneously by the insurer, and clearly is uncertain and unreliable. Litigating ERISA claims is often regarded as an un-winnable process.

Those who have employer-provided Plans should obtain a copy of the Certificate Booklet and read it thoroughly. Know in advance of a disability what you are entitled to and what the insurance company can take away.

ERISA Plans do not represent secure, reliable income and should not be relied upon for family resources. It’s like playing a game of Texas Hold’em when the other guy is holding all the wild cards.

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