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Archive for the ‘M&N Claims’ Category

In my opinion, the issue of managing mental and nervous private disability claims is rarely discussed, due in part to the sensitivity of the impairment in general. However, M&N claims have characteristics that are unique and, therefore, insurer opportunities to abuse the process are emerging at an alarming speed.

With Unum leading the sword-driven charge of insurers to use claims practices long determined to be unfair, M&N insureds are divided into two groups: 1) insureds who have primary diagnoses of mental issues and legitimately should be paid under the M&N provisions of their Plans and policies, and 2) insureds who are victims of impairment misrepresentation of physical illness in order to lessen insurers’ potential liability to age 65 or lifetime benefits.

In 2004, the California Multi-State Settlement prohibited Unum from “backdating” Mental and Nervous findings in order to deny or challenge current claims. For example, suppose Unum paid a FMS claim for four years (under the physical provision of the policy), but then currently stated there was “second look” evidence proving the claim was “self-reported”, and should have been an M&N claim all the way back to the date of disability with only 24 months of benefits. Claim denied.

According to the CA Multi-State Settlement, this practice was prohibited. However, last week I read a Unum letter to a client “backdating” mental illness in order to deny the claim currently as 24 months of benefits had already been paid. Although any insurer can “change their opinion” during the course of a claim, the proper procedure would be to pay the claim for 24 months moving forward from the date of the letter informing insureds of the change in opinion, giving insureds an opportunity to challenge the new M&N status. Unum doesn’t do that; it backdates the 24 months of benefits so that it can deny the claim now. (Or, whenever it needs the hits to profitability.)

Mental and nervous insureds/claimants are also abused in that there are constant reminders and requests for actual psychotherapy notes even when therapists refuse to release them. No Plan or policy requires the release of actual psychotherapy notes as “proof of claim”, and certainly, therapists have the right to refuse the release of proprietary note-taking if they wish. Mental health providers have finally caught up with insurers’ misuse and misinterpretation of therapy notes and most refuse to release them.

Unum’s reps send out general Authorizations to therapists requesting psychotherapy notes even when the Authorization itself says, “this does not include psychotherapy notes…” There are multiple requests for information, followed by harassment in the form   of phone calls, questionnaires, and of course, surveillance. Those suffering from mental health issues DO NOT BENEFIT from such tactics and, in fact, symptoms are worsened often to the point of suicidal ideation. Still, insurers do not let up.

Prudential persists with requests for psychotherapy notes while other insurers opt for the more expensive neuropsychological tests it can also distort and misrepresent. In other words, there does not seem to be a period of “peace” when M&N insureds can go to counseling and implement treatment plans without being harassed by their disability insurers. Insureds are expected to maintain prescribed medication levels and counseling while at the same time insurers are back-peddling harassment with paperwork and threats to deny claims. How is any M&N insured expected to improve and return to work? It doesn’t make sense.

M&N psychotherapy notes are very important to insurers because they can very easily be misinterpreted. For example, Prudential mentioned in one of its denial letters that a claimant’s therapy notes documented “her live-in boyfriend wasn’t working and not contributing to the care of her children.” Another therapist wrote, “Sharon (not her real name), reported “feeling better” and was finally able to visit her mother several hours away.” In both instances, claims were denied, unfairly mind you, but actually cited the above in the denial letters.

One M&N claimant was surveilled and was, according to Unum, “having sex in the backseat of his car with a girlfriend.” His claim was denied too!

Unum and other insurers have always abused the M&N provisions in Plans and policies using “self-reported” provisions also cited in the newer CXC LTD Plans. This isn’t something new, although CA state regulators identified M&N abuses in its Multi-State Settlement Agreement and Unum agreed not to continue the practices. Famous last words!

Just this week I contacted the Maine Department of Insurance and asked whether Unum Group was still subject to the Multi-State Settlement Agreement. I was told, “Yes they are.” The problem is, no one’s watching.

What better group of claims to abuse than Mental and Nervous when it is likely claimants are already nervous, stressed, have cognition problems, having panic attacks, not sleeping, are frequently tearful, and are unable to manage their every day lives? Harassing M&N claimants, it seems to me, is an affront to mental illness and it should be stopped.

Managing mental and nervous private disability claims is overwhelming, deliberate and an abuse of the M&N provisions in most policies. It requires insureds to be expert managers and overseers at a time when they are not mentally ready to cope with harassment and a fear of not being able to pay their bills.

 

 

 

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One of the most egregious misrepresentations  continuing to plague insureds/claimants are the allegations made by insurers that certain physical diseases are in fact mental and should be only paid for 24 months.

The new/old strategies to classify impairments as “behavioral health” in order to reduce claim liability, is as popular as ever. In so far as private disability is concerned, any mention of depression, even if it is secondary to physical disease, is presumed to be the sole cause of disability and limits benefits to 24 months.

Recently, two companies have emerged as the top offenders of behavioral health claim abuse, not surprisingly Unum Group and The Hartford. Most people are unaware that The Hartford’s management originates from Unum’s old Duncanson & Holt, and its claims strategies are primarily the same with one exception. In my opinion, The Hartford places more nickels in the surveillance-investigation bucket than Unum does.

Nevertheless, the financial reserve conflicts of interest involved in limiting benefits to 24 are so obvious, the practice is no longer “secret”. I think most people understand very clearly that mention of depression could be trouble.

Unum’s “big thing” these days is to classify “migraine impairments” as mental and nervous. While insureds scurry to obtain proof of claim from their neurologists, Unum insists “migraines” are “self-reported” and any evidence submitted is subjective.

The Hartford doesn’t even wait for final investigations to be completed. The company literally “jumps in” with both feet by having medical reviews done by a company called MCN (which you can look up on the Internet), inaccurately supporting a false narrative that there is no “objective evidence ” to support a physical disability.

Neither company’s Plans or policies require “an objective evidence standard”, a fact left unmentioned in its citations and writings. Some Unum ERISA Plans limit “self-reported” impairments to 24 months, but then again it’s Unum that decides what is and isn’t “self-reported.”

The misuse of Plan and policy provisions opens the door to increased profitability for insurers, but causes periods of unsecured financial support to those who are physically impaired and cannot return to work. Therefore, there is harm being done to insureds by corporations seeking increased profits at their expense.

It seems as though fibromyalgia, chronic fatigue, secondary depression, migraines, chronic pain, and many other impairments are “positioned” to look like mental disorders when they are clearly not. Even Lyme disease, an old impairment from the past is often classified as “mental” in order to avoid paying claims to age 65.

Insureds in this situation have 24 months to submit evidence that they are in fact “physically disabled” and not mentally disturbed. In fact, it amazes me that Unum, for example, can allege a behavioral claim when the insureds has never received therapy, and is not now in consultation with a mental health provider. How is that possible?

Still, Unum’s old abuse of the Mental and Nervous provisions of the policy remains rampant and is harming insureds and claimants as it always has.

In my opinion, all states should outlaw limitations for mental illness, that should take care of the problem. In the meantime, this is an awful situation for insureds to be in.

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Current information suggests that Unum is working with state regulators to ensure a “no contest” fall out when cognitive claims are limited to 24 months. Misuse of the Mental and Nervous Provisions always was a characteristic of Unum Life, UnumProvident, and now Unum Group, so much so that the company is obviously making sure it’s on solid ground.

There is a large spectrum of disease that can be the cause of “cognitive” impairment from mild to the most severe. Some result from physical causes such as cognitive deficit from organic brain disease, accidents or injury, and even chemotherapy. Regardless of the etiology of cognitive dysfunction,

Unum and other insurers tend to allege the impairment is “self-reported”, or mental and nervous and limit benefits to 24 months. A large percentage of Unum’s 24 month limitations are without IMEs where cognitive difficulties can be detected and diagnosed.

Resultant decisions are occasionally nothing more than the action of a claims handler who decides to allege the claim is “mental and nervous” and should only be paid for a short period of time. Such decisions make Unum’s managers happy because coding a 24  month limitation decreases the financial reserve.

Attempting to manage a ”cognitive” claim is made more frustrating when insureds and claimants are limited in their abilities to think and respond spontaneously, as well as the ability to complete questionnaires, update forms and follow-up with patient notes

Because cognitive issues are often the result of physical disease, “cognition” should be regarded by Unum as more of a symptom than a primary diagnosis. For example, a client was diagnosed with severe encephalopathy from meningitis resulting in moderate cognitive deficits. The physical cause of disability is therefore the meningitis, not cognition and the claim should be paid to age 65 not 24 months.

However, it appears Unum is hell-bent on classifying physically caused cognitive deficit as “mental and nervous” for the sole purpose of limiting its liability. Cognitive deficit, whether temporary or permanent, caused by chemotherapy is the result of breast or liver cancer, not a “mental and nervous” diagnosis.

In addition, Unum’s reviewers seem to find convent truths when reviewing cognitive claims. Those who suffer from physically caused cognitive issues are often in behavioral therapy in order to provide rehabilitation concerning daily management of activities and short cuts to increase the capability of performing daily tasks.

Even though the “therapy” is  not behavioral in nature, Unum alleges that because the insured is receiving therapy from a mental health provider, the claim is subject to the 24 month limitation. This is an abhorrent misrepresentation of the insured’s cause of disability.

This is an issue that is likely to be ongoing with Unum. My recommendation to cognitively impaired insureds is to obtain a neuropsychological evaluations with clearly recommended restrictions and limitations that explain why insureds are unable to work.

Also, a bit of warning. Some insureds mention “cognitive dysfunction” in combination with physical disease a bit too easily, thinking perhaps the addition of cognitive issues will ensure payment of the claim.

This is wrong thinking. Once “cognitive issues” are mentioned, insurers zero in on that symptom alone and may come to the conclusion that the primary diagnosis is “cognitive” and benefits should be limited. A “cognitive mention” in a disability claim should be backed up with the results of a neuropsychology evaluation, or not mentioned at all.

It’s clear though that Unum’s current issues with cognition claims, resulting in the limitation of benefits to 24 months, is likely to continue whether misrepresented or not.

If you are having problems with Unum regarding a “cognition” claim, please feel free to give me a call.

 

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Although I don’t do this very often, it’s time for a few claims managers, Unum counsel, or some power that is, to provide mentoring to their claims handlers regarding the use of the proper Authorization when requesting psychotherapy notes.

It’s come across my desk more than it should that Unum claims handler’s are sending mental health providers Unum’s general Authorization to request patient notes. Obviously, your claims handlers haven’t read the Authorization because in the second paragraph the Auth specifically says, “except this authorization does not allow for the release of psychotherapy notes.”

Although I have given this message to Unum in the past, claims handlers still have absolutely no idea that Unum has an entirely separate Authorization to Release Psychotherapy Notes. Perhaps a Unum Lead Specialist reader of this blog could do a mentoring session to make sure claims handlers understand the difference.

As for insureds and claimants with mental health claims, please give a copy of Unum’s general Authorization to your therapists and point out the (…) in the second paragraph. There IS NO AUTHORIZATION to provide mental health records with this particular Unum Authorization and records should never be sent.

Most therapists are now refusing to provide actual psychotherapy notes anyway, but if you are a claims handler at Unum and are managing claims, please make an effort to use the right Authorization instead of trying to pass off the general Auth as permission to obtain mental health records. UNUM’S GENERAL AUTHORIZATION DOES NOT GIVE PERMISSION TO OBTAIN PSYCHOTHERAPY NOTES. 

Please tell me you are not so uninformed that you do not realize you’re using an Authorization that says, “No Auth” to obtain something “with an Auth.” It looks as though Unum claims handlers use the general “no go Auth” to deceptively obtain mental health information that in reality it has no authorization for? Unum claims handlers need to stop doing this, it makes you look like a dunce.

Therefore, Unum counsel and claims managers who are avid fans of Lindanee’s Blog, please provide some mentoring to your claims staff and inform them about using the proper Authorization to obtain mental health records. Unum’s claims handlers should probably know better anyway.

Insureds and claimants – show Unum’s general Authorization to your mental health providers pointing out the Auth actually excludes permission to release mental health records. Unfortunately, some therapists do not read the Auth either. So please point out to them that should they receive Unum’s general Authorization, records are not authorized to be sent.

Psychotherapy notes should never be released without proper authorization.

 

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More and more insureds are contacting me regarding Unum’s classification of physical claims as “mental and nervous” in order to reduce its liability to pay to 24 months. Although this isn’t a new track for Unum, it’s clear mental and nervous claims have become the new-old profit center initiative.

The nefarious activities of Unum Group in administering M&N claims, including alleged “self-reported” – FMS, CFS, and Chronic Pain – are well-known by the public as well as regulators. In the past, Unum was citied for mental health provision abuse, particularly in the California Settlement Agreement. But, after the required “reassessment of claims” Unum thumbed its nose at all of the settlement agreements and continued its claims abuse reviews anyway,

Word has it that Unum’s attorneys are asking regulators questions about how much lead way the company has in enforcing “self-reported” 24-month limitations. Attempting to cover all of its bases, Unum seems to be limiting claims without justification, and in some cases the classification of M&N is downright ridiculous.

For example, let’s look at Mary’s claim. Mary was diagnosed with herniated and bulging discs after several failed back surgeries for which there is a preponderance of objective evidence to prove she has what her physicians say she has. Mary’s current treatment is medication management of her chronic pain related to these diagnoses.

Yet, Unum, took it upon itself to classify this disability as “behavioral” which it clearly is not. The word “behavioral” refers to mental issues including depression, anxiety etc. Mary has never received counseling, or any type of therapy, and has never had a “behavioral” issue in her life.

Mary sent Unum more than 150 pages of objective evidence proving her thoracic and lumbar back diagnoses. Unum  still denies Mary suffers from physical back issues and her claim is NOT subject to the 24-month limitation. Since when is a history of failed back surgeries “self-reported”?

My prediction is that Unum will be spending a great deal of money defending its allegations of “self-report” in the courts. Unum is definitely the company of “No” and the general public should be aware of Unum’s abuses of the mental health provisions in Plans and policies.

 

 

 

 

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As a consultant I’ve always held the opinion there is something inherently wrong with a disability insurer who sends a letter to an insured with inaccurate statements. In fact, some statements are so obviously inaccurate one has to wonder whether those who make them are qualified to review claims at all.

Mass Mutual recently sent an insured a letter stating, “…as a patient you are entitled to these [psychotherapy notes] records.” This statement is grossly inaccurate and I would have thought Mass Mutual would know better.

Very rarely will therapists and psychiatrists release their patient notes directly to mental health patients. It makes good sense not to do so since what is contained in the records could potentially be harmful to those who are reading them. In some cases, therapy notes have been noted to be the cause of patients attempting to hurt themselves and therefore, it is generally recognized that therapy notes should not be released to mental health patients.

In addition, therapy notes are regarded by mental health professionals as proprietary to them written for the purpose of “reminders” of what took place during therapy sessions. Therapy notes are NOT written for the purpose of verifying disability through mental health restrictions and limitations. Mental health providers now regard patient notes as private references for their eyes only.

Over the last several years those who provide mental health therapy have noted the misuse and misrepresentation of information by private disability insurers to the extent that they themselves have office policies not to release therapy notes to anyone. More often providing “actual psychotherapy notes” to companies like Prudential and Mass Mutual hurts insureds more than they help.

Here’s how:

Patient notes rarely document “affect” which is an observation of how the patient’s reactions are, (flat or normal), and therefore insurers use this omission to deny claims. Prudential, for example consistently states in denial letters that the therapist failed to comment on “affect” and denies claims just on that basis.

Most behavioral therapy does not require neuropsychological or other tests to diagnose clinical depression and many other anxiety states. Yet, insurers look for documentation of “objective testing” in the notes when most therapy does not require it, or there is a lack of psychological tests available to diagnose specific conditions. There is a non-acceptance of WHO DAS 2.0 (in lieu of the GAF Score) by insurers, and clearly isn’t considered “objective evidence.”

In other words, if the actual psychotherapy notes do not contain exactly what Prudential and Mass Mutual want to see, claims are denied. The expectation that all therapists document what is needed by insurers to evaluate claims is unreasonable and ultimately unfair.

In the past, Unum denied a depression claim because surveillance showed the insured having sex with his girlfriend in the woods. Patient notes were submitted to Unum but were not considered as compared to the surveillance. Therefore, according to Unum those with depression aren’t supposed to be having sex. What idiocy!

Recently, Mass Mutual threatened an insured with claim termination if he didn’t obtain his therapy notes and submit them. Mass Mutual’s claims manager told me personally, “Those records belong to him and he needs to obtain them and provide to us.”

The letter clearly said, “No additional payments will be made until we receive the daily treatment records from [your doctor]. What if this patient’s therapist refuses to release his patient notes? Should Mass Mutual penalize the insured because his therapist refuses to release notes? And, even if the psychotherapy notes were released, Mass Mutual (Prudential in particular) will allege the notes do not contain sufficient detail to continue to pay the claim.

Are you getting the idea that mental health insureds and patients are “clucked” regardless of what they, or their therapists do?

In any event, Prudential and Mass Mutual continue to insist on psychotherapy notes, which by the way, is an out-of-contract request. No where is anyone’s policy or Plan is there a duty or requirement to submit actual psychotherapy notes as “proof of claim.”

When I asked the Mass Mutual claims manager to fax me the page from someone’s policy requiring submission of actual psychotherapy notes, she gave me the run around and then said, “but our Authorization allows us to request them.” That’s true, Authorizations may request submission of notes, but that doesn’t mean the therapist is willing to release them.

Unfortunately, ERISA Plans often include the phrase, “…satisfactory to us…” which  permits “discretionary authority” to the insurer to decide what is and what is not “proof of claim.”

Mental health claims remain a constant source of controversy as insurers continue to deny claims for failure to submit actual psychotherapy notes they may not be entitled to.

Therapists should be able to submit mental health restrictions and limitations in summary form (filling out forms or submitting letters) rather than giving up patient notes not intended for the validation of private disability.

 

 

 

 

 

 

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There’s been a great deal of interest and inquiry to the Blog lately about “mental and nervous” private disability claims (M&N). Therefore, I hope this article provides the information you are looking for as well as being a great addition to the blog catalog.

Most Employer Group Plans limit M&N claims to 12 or 24 months and can contain additional restrictions for what is called “Self-Reported” impairments. Obviously, employers are reluctant to pay for expensive policies that could pay to age 65 for impairments related to addiction, mental illness. or episodes of anxiety, stress and nervousness.

Clearly, ERISA folks suffering from mental and nervous conditions receive limited and restricted benefits from their Plans. IDI policies may or not include mental health restrictions, but in general, do NOT include limitations for M&N claims.

Although ERISA insurers look to stop paying M&N claims after 24 months legitimately, insurers also abuse mental health provisions by deciding for themselves what is self-reported and what isn’t. Co-morbid physical impairments are ignored by insurers in order to pay only for the limited M&N time period.

Plans also can specifically exclude certain physical impairments such as tinnitus, connective tissue disease, (any FMS-like diagnosis), migraines, cognitive issues unrelated to dementia or Alzheimer’s under the Plan’s M&N provisions. Insurers continuously look to find loopholes in their current Plans so that benefits can be limited to 24 months.

In addition, in 2015 the new DSM-5 classified all of the “syndromes”, such as Chronic Fatigue Syndrome, Chronic Pain Syndrome, Fibromyalgia, and many others, as “somaticized” or “imagined” impairments, opening doors for insurers to shut-down claims for what were formerly classified as “physical disability.”

First, a few definitions. mental and nervous illness is defined (for private disability purposes) as impairments listed in the Diagnostic and Statistical Manual, or DSM-5. Period. Claimants can do their own further research of the DSM-5 on the Net if interested to locate information for specifically named conditions.

However, “mental illness” is generally accepted to mean clinical diagnosis such as Depression, Bipolar and Personality disorder, Schizophrenia and OCD. “Nervous disorders” include panic attacks, stress related anxiety, anxiety attacks, PTSD and so on. Private disability Plans may also include, or exclude alcohol and drug addiction or limit benefits to 12 months.

Although most insurance companies request actual psychotherapy notes as proof of claim most therapists today refuse to release them. Recognizing how insurance companies “snatch” and misrepresent information, therapy professionals consider their notes as proprietary to them and refuse to turn them over to insurers looking to deny patients’ claims.

Unum, for example, often sends mental health providers their general Authorization to Release information form that specifically says, “does not include actual psychotherapy notes” hoping most professionals won’t actually read the form and release patient notes anyway. Claimants should always discuss not releasing psychotherapy notes with their therapists with a reminder to actually read Authorization forms.

Continuing, UnumProvident was cited in the California Settlement Agreement for unfair practices of backdating M&N claims so that it could always allege, “We’ve already paid 24 months of benefits, so good-bye claim.” Although Unum agreed to change that practice I’ve currently seen at least one incidence of backdating M&N impairments and denying claims suddenly without notice.

Finally, in addition to Plan M&N benefit limitations, some insurers are stating specifically in the Plan they will not pay for FMS, CFS, connective tissue disease, migraines or any impairment of chronic pain. At least this is more honest in that the Plan specifically states what it will pay for and what not.

It’s important for claimants to understand that at least to some degree “mental and nervous illness” is self-reported even though there are psychological tests that diagnose the more serious conditions.

You can be sure that whenever insurers have the opportunity, they will always be looking to classify physical impairments as self-reported so that the liability for claims is reduced.

Constant requests for actual psychotherapy notes will be made. Prudential denies claims if psychotherapy notes cannot be obtained, but then again Prudential also denies claims when they are provided due to misrepresentation and documented reviews written by nurses. Prudential M&N claimants are indeed between a rock and a hard place.

It is extremely important for M&N claimants to understand the abusive nature of mental illness claims for private disability. This is an area that is specifically abused in ERISA Plans.


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

If you need assistance with your mental and nervous claim please feel free to contact me

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

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

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

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