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Archive for the ‘Claims Process’ Category

Although one could easily say that CIGNA makes extremely unfair claims divisions, it is also true that the company is negligent, chaotic, disorganized, and incapable of providing any type of reliable customer service. How would anyone recognize an egregious claims decision with all this incompetence?

A recent claim situation involved a denial that CIGNA forgot to tell anyone about since there was no official denial letter sent to the claimant. The claims handler later agreed to review information that was “omitted” and an 83-page fax was sent. Yesterday, when I tried to verify the information was received, I was on the phone for an hour with reps who had absolutely no idea what was going on in claims.

I was told the claims handler “Marina” was not in the office, and neither was Nichols, her claims manager. I was transferred to the wrong department several times, and then placed on eternal hold. One hour later, I still didn’t know whether CIGNA received my 83-page fax or not.

This is just one more impossible incident in a long line of years of experience trying to make sense of CIGNA’s gross negligence and why it is still permitted to do business. Today, I’m contacting the department of insurance with a complaint and also requesting its help to find out whether the 83-page fax was received. Maybe the DOI can raise the CIGNA dead in customer service!

Although CIGNA was fined in a 2014 Settlement Agreement the company completely ignored the directives and have continued to engage in its own foolish disorganization and prejudicial claims process. Claims handlers speak as though they are oblivious to the claims process and offer no help at all.

In addition, CIGNA is the ONLY insurer who insists on having contact by phone with treating physicians before it pays claims. Insurance doctors make phone calls to treating physicians, and if they cannot make contact on the first call, claims are immediately denied. Physicians who “call back” find their patients’ claims have already been denied.

I’ve also found that in claim situations where CIGNA overturned a denial on appeal, or agreed to pay claims, the company turns directly around and orders surveillance again, and again, hoping to re-deny the same claim. There are plenty of indications the company depends heavily on surveillance and non-responsive doc-to-doc calls to deny most of its claims.

Interestingly, CIGNA is also infamous for not signing its letters with the claims handler’s full name. If I worked for CIGNA I’d also be afraid of signing my full name to a letter that is essentially a grammatical and confused mess! Who is running CIGNA’s negligence anyway?

In my opinion, CIGNA is clearly a disability insurer that should not exist. Employers really need to be kept informed of the confusion and disorganization that surrounds a CIGNA claim. CIGNA’s group claims may be cost effective, but employers get exactly what they pay for at the expense of disabled employees.

While Unum’s mantra is to target and refuse to pay legitimate claims, CIGNA operates under a grossly negligent claims process where anyone who works there doesn’t have a clue.

Again, in my opinion state regulators need to take a second look at CIGNA’s gross negligence and do something about it.

 

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Information overloadMost people who have a disability claim have a tendency to provide insurers with as much information they possibly can.

Although the idea that the more information provided to an insurance company is the right thing to do, it is in fact, providing insurers with its next question, or area of investigation.

I have actually heard insureds say, more times than I care to mention,” It doesn’t matter what I tell my insurer, I didn’t do anything wrong.” In reality, while insureds are NOT doing anything wrong, insurers are working diligently to misrepresent what they hear, what they see and what they investigate.

Perhaps you’ve read in my articles my use of the term, “stacking the deck” to describe private insurance investigations. Needless to say, the more information insureds provide to insurance representatives, the more insurance jokers are added to insure more claims are not paid, particularly prior to profitability reporting periods.

A good case in point is that of a woman insured who lost her house during the hurricanes this past summer. In attempting to persuade Unum she is legitimately disabled she wrote lengthy letters describing the victimization of herself and her family during and after the hurricane occurred. She did this because Unum asked her to fill out the normal update forms.

Insurance companies that request “update forms” should receive competed “update forms” providing exactly the information it asked for. However, there are insureds who take this opportunity to add pages to the forms disclosing  information about family and activity that is not part of a disability claim. Insurance companies should always be provided with the information it asks for, and nothing else.

The idea that insureds MUST provide every piece of information about themselves stems from the fear that claims won’t get paid even though the exact opposite is true. How many times have you filled out your disability forms and realized there were no empty spaces on the form at all? That’s too much information!

I know from experience that on those occasions when insureds submit old information, it is placed swiftly in the trash (not legally, mind you), but it isn’t paid attention to. When there is INFORMATION OVERLOAD insurance companies tend not to pay attention to anything submitted even though there may be valuable, supportable evidence included among the paperwork.

Writing long defensible letters to insurance companies may also result in denied claims. Insurance managers view such letters as evidence of work capacity. While I understand insureds’ needs to “defend, defend, defend”, letters more than a few paragraphs are considered evidence of work capacity.

The message here is that insureds and claimants should provide answers to only the questions asked and nothing more. These answers need to be truthful and to the point. Insureds should not speak verbally to representatives on the phone, but ask for all communications is writing. Those who are taking opiate, or depression drugs should never be giving information on the phone anyway.

Finally, insureds should immediately restrict themselves from social media. Insurers are tuned in to Facebook, Twitter, LinkedIn, MySpace and many other chat rooms and are using investigative software. Most insureds and claimants have no idea how in-depth Internet investigations are. It’s best not to be on social media at all when you have a disability claim.

Remember, no insurance company can hold against you what you do not say or write. Refrain from overloading insurers with personal information it could care less about, or could use against you in the future to deny your claim. If you are calling your claims handlers often, you need to stop – frequent calls are considered red flags.

Also, this is not the time of year to be chatty with any disability insurance company. Answer only the questions you are asked and nothing more.

 

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Christmas GrinchThis time of year is extremely stressful for those who work in the disability claim areas of major insurance companies. Claims managers visit cubicles of employees armed with named targeted hit lists of those whose claims won’t be paid in the new year.

Already, CIGNA has emerged as the major harbinger of doom as the company continues to deny claims indiscriminately without investigation, cause or reason.

Obviously,  CIGNA’s 2013 Multi-State Settlement did nothing to improve the inefficient and negligent claims process that is earmarked by untrained, lazy and inefficient claims handlers. But, that doesn’t help claimants who are depending on benefit income for the Christmas season.

Unfortunately, MetLife, The Hartford and Mass Mutual are also pushing the boundaries of “claim target management” by requesting more IMEs, surveillance, field visits, questionnaires, and repetitive requests for patient files. If you’ve received multiple requests for the above since October, you are most likely a victim of year-end targeting schemes designed to deny claims when profits are most needed.

Reducing financial reserves and accumulating multiple profitability hits is a major objective of every disability insurer in the United States. For example, claims with over 1M in financial reserve will immediately contribute 1M to Balance Sheet profitability when they are denied.

You may have noticed I haven’t mentioned Unum Group thus far in this article and, well, in my opinion, Unum is still the Village looking for its idiot. Apparently, the company is lurching forward with Lucens requests for SSDI financial information in order to find a dollar here, and a dollar there, in overpayments it can recover.

Unfortunately, I’m still getting the impression that Unum is a company searching for its Leader who has gone off with an Atlantean alien to discover the ultimate Gnome on another planet. Outsourcing its operations to “black matter” in the universe doesn’t seem to be working all that well for Unum – at least so far.

Lately, playing “bad cop, good cop”, Unum tends to bend with the wind in its denials and doesn’t seem to have a distinct direction on anything. I’m sure Jim Orr III’s perception of his  former Unum accomplishments as CEO also agrees with mine in that Unum has gone from the “Lighthouse” to the “Outhouse” in a little more than a decade.

Still, Unum’s end of the year profitability targets continues to appear in the form of repeated questionnaires and doc-to-doc calls. Insureds and claimants should be wary of insurance doctors communicating denial agenda to treating physicians, who sometimes agree when pressured.

All in all, December is the primary “target” month for private disability  insurance leading insureds and claimants in “watchful mode” to prevent claims review abuse.

All insurance companies earn profit by NOT paying claims. And, I’s sure no one wants a claim denial delivered by their particular insurance Grinch during the coming holidays. If you need help, please give me a call.

 

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denial-cartoonToday, it is the trend of highly paid professionals to invest, or be involved in many different enterprises. Doctors, dentists and self-employed executives diversify their interests and receive income from many different sources such as K-1 income derived from Partnerships or LLCs, and other corporations including several sources of self-employed income.

While it may be considerably profitable while healthy to be heavily divested, it clearly may not be of benefit to insureds when filing a disability claim, particularly with Met Life. Issues of determining what income is “passive” vs. “non-passive” can quickly turn a total disability claim into a residual disability paying 50% or less of benefits.

Met Life’s review process includes a review (that takes a very long time to do) involving passive and non-passive income. “Passive income” is income for which the insured does nothing to earn and therefore is most often identified as investment or equity income. Non-passive income is “earnings” for which there are K-1s and W-2s.

Of course, Met Life’s method of identifying passive vs. non-passive income is its own self-interest for doing so. Paying half benefits for Residual Disability is preferable to paying 100% total disability. Met Life’s strategy is to allege it is “adjudicating” policy definitions without regard to passive and non-passive income.”

Still, insureds should be aware that Met Life’s ability to allege a duo-occupation with multiple sources of pre-disability income may wind up being an unexpected “Residual” disability claim rather than total disability.

Again, while it is profitable to have income from many other sources prior to disability, disability insurers have devised strategies to pay reduced benefits under the Residual provisions of the policy by misrepresenting what is passive and non-passive income.

If you have any questions about this, please let me know.

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There seems to be a great deal of confusion as to when the insurance company pays for medical information and when the insured or claimant foots the bill.

If the insurance company sends you, the claimant, regular and customary update forms to give to your treating physicians for completion, then you are required to pay the bill. In fact, most ERISA Plans contain specific language that claimants are responsible for providing “proof of claim” at their own expense.

HOWEVER, on those occasions when insurers send forms directly to physicians for completion, the insurance company pays the bill. In my opinion, physicians are cheating themselves from collecting fees for their time.

In reality, physicians should be charging insurers not only for their time, but for use of office machines (computers and photocopying), and office personnel in addition to the actual time spent in filling out the requested forms. Some physicians begin by charging $100 per request and then increasing the fee by $100 increments when multiple requests for the same information are received.

Treating physicians will often fax the insurance company an invoice for the required fee with a note stating that once the fee is received he/she will provide the information. Even physicians don’t trust insurance companies when it comes to payment.

So, the rule of practice is actually very simple – if insurance forms are sent to you for your normal update from your physicians, YOU pay the bill.

When forms, questionnaires, narratives or patient note requests are sent directly to treating physicians from insurers, the insurance company pays invoices sent to them by the treating physicians.

If your physician hasn’t been billing insurers for information requests sent to them directly they are cheating themselves out of fees for their time and use of office resources.

Please speak with your treating physicians and make them aware that any requests they receive directly from your insurance company are billable opportunities. I find that when physicians bill your insurers it keeps them from requesting (or losing) the same information over and over again.

Physician billing actually keeps insurers from harassing physicians for frequent information, and it keeps the insurance companies honest about obtaining only the information they need.

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Nearly every disability insurer has their own special gimmicks to encourage insureds and claimants to do what they ask without question. I call them “Why Lies” because the insurance industry, or insurer is attempting to justify “WHY” they are doing what they’re doing with a deliberate “LIE.”

The top “Why Lie” on my list is this statement, ” …please submit the above requested information so that we can give your claim every possible consideration before making our decision.” Unum uses a variation of this statement every time it requests SSDI Authorization signatures to obtain SSDI files.

No disability insurer ever looks for information “to give your claim every possible consideration” since there is always a profit agenda involved somewhere. For example, Unum requests SSDI files in order to obtain listing codes (Form 831) to determine if SSA classified the disability as mental or nervous. Even when SSDI files ARE obtained, Unum disregards favorable decisions using the rationale, “Since we have more current information about your medical condition that was not previously available to SSA, we disagree with SSA’s approval decision and deny your claim anyway.”

Another “Why Lie”, also used by Unum, is “…we are requesting a field visit to give you an opportunity to meet with us and ask questions concerning your claim.” What? Since when are insureds and claimants overly anxious to meet with disability field investigators to have questions answered?

The real reason for a field investigation interview is so that the insurance company can have you personally profiled, and encourage you to feel comfortable enough to share information that could be used adversely against you. The management template of questions provided to field reps asks for the same information that you provided earlier in the claim history.

Unum also uses the same rationale to encourage insureds to speak with its representatives on the phone.

Finally, another popular “Why Lie” is, “…we’re requesting this IME to clarify your medical restrictions and limitations.” Clearly, this is untrue. Insurance IMEs are insurance defense strategies required for the purpose of obtaining what appears to be credible evidence that insureds and claimants are able to work in some capacity. Insurance defense IMEs are a million dollar a year industry bought and paid for to “further enhance insurer objectives” – if you believe the marketing materials third-party facilities are advertising on the Internet.

I hope by now my readers are smart enough to recognize a put-on when they see one. All disability insurance companies are profit motivated, and most operate to deny claims rather than pay them. And, they all document statements in their letters to encourage the unknowledgeable to do what they say regardless of the fact that the requests are often  out of contract or Plan.

Insurance companies tell “Why Lies”, but a smart insured or claimant should be able to identify the truth from any profit agenda. Frankly, the “Why Lies” do insult my intelligence as they should yours as well.

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Most private disability insurers are now outsourcing most of their risk management activities to third and fourth parties in an effort to remain an arm’s length” away from adverse claims decisions.

The concept of “arms length” transactions stems from the accounting profession directing accountants to remain “at least an arm’s length away from actual transactions” in order to maintain objectivity. Insurers who keep a distance between themselves and denial decisions can allege to be objective in their assessments.

Recently I wrote a consultant’s report for an attorney and noticed that the insurance company, Prudential in this case, remained not only one arm’s length away from the denial decision, but two. For example, Prudential retained MES who then hired a professional peer review company to review the claimant’s file and medical information. It was the third facility in the line of reviewers who actually made the denial decision, backed up, of course by Prudential. The denial letter was actually written by the third-party facility reviewing the claim.

It’s not difficult to speculate on the motives behind the passing off of fiduciary duty to second and third parties who I presume are assuming at least a co-fiduciary status as agents of the insurance industry. In addition, hiring third-party reviewers who are paid a flat fee are much cheaper than internal employees who must be provided with benefits, including the co-pays of FICA and Medicare taxes.

As agents of the original insurers these new “professional” facilities are selling themselves as experts of the medical and vocational review status of disability claims. The fact that they “assist or aid” insurers with their own goals and expectations, notably profitability is also described in their marketing materials, a sure give away to claimants that the process is corrupt with conflicts of interest.

The “new arms length” physicians work for the insurance industry in areas such as private disability, developing employment standards, and worker’s compensation. The physicians agree to the objectives of the facility they are working for and meet standards that are consistent with the profitability motives of employers (worker’s compensation) and insurers.

In some cases, the new “paid reviewers” actually teach their physicians and neuropsychologists what tests to administer and how to identify AND DOCUMENT malingering. When the report is reviewed by the facility it is given a specific “grade” as to  how well it met the “examining criteria.” How is this fair? Or, objective for that matter.

Therefore, it appears the trend in disability claims review is to hire outsourced agencies to review claims and make “appropriate decisions” as third-party administrators, to the detriment of insureds and claimants who believe they are getting a fair shot.

In the back of my mind I can hear a distinct, “we didn’t do it” echoing from insurers who are held accountable in the courts for the decisions their agents make. Testimony and depositions will consist of information given by third-party professionals with  impressive credentials in lieu of, let’s say coached Prudential claims handlers.

The new “arms length” transaction has become a very clever scheme to keep insurers  protected from actual bad faith and egregious claims decisions made by a new generation of proposed “experts” who are more biased than ever.

Claimants can expect to see more and more claims decisions made by alleged “professional evaluation” facilities outside of the original insurers domain. Although the intent is to shield insurers from perceived bias, it remains clear that claims decisions still go to the highest bidder and those who are paying the fees.

 

 

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