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Archive for the ‘Claims Process’ Category

In the past the people of Great Britain suffered because of its welfare system’s use of something called ATOS, now discontinued. Those who applied for “disability welfare” were determined eligible, or ineligible, by a computer system (ATOS) with no human intervention. Amidst a great deal of protest and civil action, ATOS was eventually done away with.

Meanwhile in the United States, Unum (the co-inventor of ATOS), also uses a computer software called Medical Advisor (MA) to determine “when insureds SHOULD be better”.

Of course, MA doesn’t take into consideration that people improve and “get better” at different rates, and I suspect the use of MA allows the company to reduce its medical staff and require fewer RN walk-ins. I also suspect Unum may be using MA to set ERDs (Expected Recovery Dates) that are really drop dead dates for claim denials.

Recently, I received an email from someone who had been admitted twice as a mental inpatient for two attempted suicides. Diagnosed with schizophrenia, Unum continues to harass him since “he should be better in 12 weeks.” This kind of statement reeks of Unum’s use of Medical Advisor that also assumes the program is used by medically savvy claims handlers.

To my knowledge schizophrenia does not go away in 12 weeks and it is extremely inappropriate for Unum to allege this claimant can go back to work without restrictions. Having used MA myself when I was employed by Unum, it seems to me one of Unum’s village idiots looked up depression and anxiety and got 12 weeks.

Unum’s management is extremely remiss in allowing claims handlers to use Medical Advisor without adequate training. It is also acting in bad faith, if in fact the review process uses MA to set future recovery dates – really claim denial dates in disguise.

Rumors continue to abound that Unum Group downsized again and is cutting corners on the review process to the point of negligence. I heard several months ago that Unum trains its newbie U-numbies to “suspect” every claim and investigate as much as possible.

This is a philosophy that came to the company via Harold Chandler, Ralph Mahoney and his henchmen from Chattanooga in 1999. At one time ERDs were connected to financial reserves so you can see how important it was to use MA and set ERDs to the shortest period of time.  Fortunately, for insureds and claimants Unum’s ERD fiasco was discovered and ERDs were removed from financial reserve coding.

Nevertheless, it appears that Unum is once again using a medical coding software to pinpont (target) when claims can be denied. Using artificial software to determine human recovery dates isn’t accurate and Unum should know better since it never really worked the first time around.

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This is a reminder to all insureds and claimants that private insurers have already targeted claims within their own review process for potential denials. The motivation behind profit terminations is, of course, to bolster reported income for third-quarter.

Claim terminations can be sudden just prior to profitability timelines and it is left up to insureds and claimants to defend their claims, policies and Plans. In all fairness to Unum, and I assume other insurers are doing the same, special considerations have been made to extend deadlines due to the hazardous times caused by hurricanes in the southern United States.

Although claims elsewhere will continue to be denied, at least insurers are willing to make exceptions to those who have other things to worry about right now. Still, it’s always a good idea to be on the lookout for unreasonable requests particularly those with short deadlines.

The ERISA folks have 45 days to provide proof of claim, not 5 days as sometimes requested. Please stay diligent when managing claims during periods of profitability.

 

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In today’s current insurance environment some insurers are engaging outside, third-party resources to manage ERISA group claims, STD and LTD, using standardized technology and “objective evidence” standards to review claims.

Prudential, for example, utilizes “The Reed Group” that openly advertises its prejudice in favor of insurance defense holding claimants hostage to what is called MDGuidelines administered without consideration of the uniqueness of each individual claim.

For starters, none of Prudential’s ERISA Plans require an “objective evidence standard” in order to receive benefits. Yet, “The Reed Group” applies what they refer to as “evidence-based” standards – a phrase meaning the same thing as objective evidence.

The cleverness of Prudential and other insurers who employ these so-called “standardized reviewers” alleging credibility is not going unnoticed by the public who immediately identifies the “set-up.” “The Reed Group” then employs “ECN”, Exam Coordinator’s Network to arrange for IMEs. Notice that by engaging these outside resources Prudential is actually three times removed from the claims process.

“The Reed Group’s marketing statements defining MDGuidlines states the following:

“Our evidence based clinical content that delivers intelligent, point of care clinical decision support, physiological duration tables, analytics, and consultative services that empower employers, insurers and provider to successfully improve outcome, promote active lifestyles and achieve tangible ROI.”

Does this sound like a fair and equitable review to you upholding the ERISA requirement of fiduciary accountability? I think not.

“The Reed Group” is not the only third-party administrator out there. In fact, Sedgwick  has been in the loop of third-party administration for quite some time, specializing in state-run pension and employment disability.

While these organizations sell themselves as models of impropriety, the conflict of interest to serve those who pay them is obvious. These organizations are purely insurance and employer defense mechanisms.

“The Reed Group” identifies the insurer as OUR SOURCE in the Administrative Record, and employs Registered Nurses for case management. This is consistent with Prudential’s old bad habit of relying on medical reviews conducted by unspecialized RNs and not MDs.

The “claims process” per se is performed without weight to each individual claimant. As a result, claim reviews are conducted by highly sophisticated outside resources that know exactly what to document to provide proof claims should be terminated. It’s likely companies such as “The Reed Group” have access to statistics and actuarial information that could persuade courts and legislators that certain claims should be denied.

Insureds and claimants should know that these new procedures are not necessarily dead ends for insureds, but that it is critical to know exactly what to do about it.

Unfortunately, the new trend in disability claim review is removing the insuring company as far away from the claims process as possible and replacing them with companies specialized in the science of terminating claims – a sad testament to the insurance industry as a whole.

 

 

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Unum’s internal claims review strategies have received a great deal of criticism over the last decade causing many insureds and claimants to be cheated out of benefits they are legitimately entitled to.

Interestingly, Unum, and probably many other insurers, use strategies like those used in the past by professional boxers referred to as “Rope-A-Dope.” The term gained popularity after the infamous Foreman vs. Ali fight when Ali allowed himself to be hung up on the ropes and then “knocked out” and exhausted Foreman, the favored winner of the match.

“Rope-A-Dope” actually refers to a strategy wherein one boxer allows himself to get hung up on the ropes and allows the other to literally exhaust his energy before going in for the big knockout. Simply put, one player allows the other to become exhausted and then goes in for the kill (knockout).

Disability insurers use virtually the same strategies to wear claimants down before claims are denied. Consider.

  • Unum begins the claim with a 10-page set of application forms and then follows up with a  phone interview (not my clients), encouraging clients to talk and provide much more information than is necessary to investigate any claim.
  • Unum then proceeds with a process whereby multi-paged letters are sent out to insureds and claimants regurgitating policy provisions most people find confusing. These letters often arrive twice a month to begin with, then decrease to monthly, then every other month. The letters always say, “We are continuing our review of your claim; it is never really clear that Unum accepts liability for the claim.
  • After claims have been paid for more than 6 months, Unum hangs itself “on the ropes” and exhausts insureds with requests for field visits, forced applications for SSDI, IMEs, surveillance fears, multiple requests for medical information, and menacing phone calls.
  • After insureds are “exhausted” from all of the “risk management” activity, Unum goes for “the big knockout” and denies claims – a clear “Rope-A-Dope” process of exhausting your opponent then going in for the big knockout.

What most insureds and claimants fail to realize is that Unum’s strategies are planned, deliberate actions intended to gather information sufficient to deny more claims. Since the intent is deliberate such strategies could be described as “patterns of practice”, or in other terms “racketeering.”

It is also true that insurers who do this deliberately consider their insureds and claimants to be naive “dopes” unable to “figure it out.” According to Unum insiders the company is now training its claims handlers to immediately “suspect” new claims and engage in multiple risk management activities, an exhausting process of phone calls, letters, requests for information, surveillance, field visits and IMEs.

Those who are currently managing their own claims may recognize the process now that its been explained. How many times does Unum contact you? Ask you for additional information? Contact your treating physicians? Send you letters to the point you become fearful of the mail and opening anything from Unum? As a company, Unum is deliberately exhausting you sometimes to the point you will say anything to make them go away and get off the phone.

Clearly, these tactics encourage you to exhaust yourselves with fear and running around trying to meet Unum’s constant requests. DCS, Inc. is often contacted by those who have become exhausted of the claims process and ask for help.

The next time Unum hangs itself up on the ropes, don’t be its “Rope-A-Dope” and wait around for the knockout.

When it comes to defending disability claims, insureds can often come up with their own “right hooks.” Knowledge is power in the insurance industry and it’s time insureds and claimants recognize a “rope a dope” strategy when they see one.

Knowing what insurers do, particularly Unum Group, and why they do it is a big step toward defending any private disability claim.

The next time Unum hangs itself on the ropes waiting for you to exhaust yourself, just knock ’em out of the ring with fearless calm. Unum’s management hates that.

 

 

 

 

 

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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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