Archive for the ‘M&N Claims’ Category

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.


Read Full Post »

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.


Read Full Post »

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.





Read Full Post »

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.







Read Full Post »

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

Read Full Post »

All of Unum’s ERISA Group policies contain provisions limiting payment to 24 months for mental and nervous conditions.

Unfortunately, Unum also has a longstanding history of abusing Mental and Nervous limitation provisions for which the California and Multi-State Commissioners fined the company and demanded changes in its claims review process.

Although Unum adhered to its agreements during the reassessment, it didn’t take the company very long to return to its abusive practices using the M&N provisions of its policies to deny or limit benefits.

Here are  Unum’s specific abuses of the mental and nervous provisions of policies:

  • Using misrepresented internal medical reviews to identify physical impairments as self-reported in order to limit benefits to 24 months. (For example, cardiac patients receiving therapy for depression following open heart surgery.)
  • Subjecting claimants to 24 month limitations because of reported “symptoms” instead of using treating physician diagnoses for physical impairment.
  • Classifying “cognitive disorders” as self-reported even though related to physical disease resulting from objective evidence.
  • Alleging lack of “objective evidence” for FMS, CFS, Lyme Disease, MS, Lupus, and reclassifying physical disease and subject to the mental and nervous limitations.
  • Classifying “pain” as self-reported when it is a symptom of a physical disease objectified by medical evidence. (MRI and x-ray evidence indicating back impairment causing pain.)
  • Back dating claims to earlier M&N periods due to alleged “reclassification” of impairments that “should have been” paid only to 24 months allowing denials of claims on the spot.
  • Not acknowledging “clinical diagnoses” as credible, or applying the “objective evidence standard” when no such standard exists in Unum’s policies.
  • Abusing “Self-Reported” terminology to include illness that is clinically diagnosed, or impairments for which medical science has no clear or specific testing available.
  • Using deception to obtain claimant SSDI files (Form 831) for the purpose of finding out whether claimants have been awarded SSDI benefits via mental health SSA listings and then denying claims on that basis.

In reality, Unum continues to do all of the above even though, for example, the California Settlement Agreement stipulated that Unum should not “backdate” mental health claims. If it should happen legitimately that Unum “discovers” a primary mental health issue later in the claim, the 24 month clock begins ticking at the time of the discovery, and cannot be back dated in order to deny claims currently because the 24-month limitation has already expired.

In addition, the DSM-5 has not helped claimants much by reclassifying otherwise physical impairments as “somaticized”, or “all in your head” complaints. Unfortunately, FMS and CFS, among many other “syndromes” fall into this category thereby opening the door to  dishonest insurers to allege impairments are “self-reported” or subject to the 24 month limitation.

Another example, are those on disability for addiction for alcohol and drugs. Over the last 10 years or so changes have been made to Group Plans such that alcohol and drug addiction is now classified as “mental and nervous” and limited to 24 months.

Claims handlers from other insurance companies such as Reliance Standard inaccurately  use date of disability as the beginning of  the 24-month limitation. This deprives claimants of the full 24-months of paid benefits guaranteed under the policy.

It is disappointing indeed that insurers, particularly Unum, are still allowed to “get away with” deceptions of mental illness to limit legitimate benefits to 24 months. Despite agreements with regulators to stop the practice, Unum continues to thumb its nose and engage in deception for profitability sake.

Claimants need to be particularly aware of the deception and obtain assistance with they need it.

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 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 am here to help.

Read Full Post »

Mental Health AwarenessAny discussion of mental health awareness and disability claims should mention the internal strategies of Prudential that gives the phrase “snatching” an entirely new meaning. Although group disability plans and most ERISA policies do NOT contain specific contractual provisions requiring claimants to “give up” or release actual psychotherapy notes, insurers often throw their full force of abusive discretionary authority in that direction.

Psychotherapy notes are not written by therapists to support disability but as reminders of what transpired during specific therapy sessions. Patient therapy notes belong to therapists who may decide whether or not to release them to insurance companies they know will “snatch” information favorable to corporate business interests at the expense of all else in the record.

This is why today most therapists are refusing to release therapy notes to any outside third-party. Nevertheless, Prudential “insists” their RNs cannot make claim decisions without therapy notes even when R&Ls are provided in summary form (on forms, in letters etc.). In an out-of-contract manner, Prudential threatens claimants with denials unless mental health providers give up the notes. Scared of not receiving benefits, claimants and therapists given in to Prudential’s threats.

Assuming that Prudential reviews therapy notes fairly, once provided, is a big mistake. I am reminded of a recent claim situation I reviewed by reading a Prudential denial letter for a valid PTSD claim of a single mother. The 5-page denial letter cited nearly every detail “snatched” from therapy notes such as the claimant’s husband was unemployed for 5 years and couldn’t find a job (the claimant isn’t married.); all the claimant wanted to do was stay at home and be a good mother; the claimant felt better on some days etc. Prudential then took this information and alleged the claimant “didn’t want to work and preferred to stay at home because her husband wouldn’t work.”

This is what happens when actual therapy notes are “snatched” and misrepresented to create illusions of “wrongful intent” that does not exist. How does Prudential know what the intent was of a single mother suffering from PTSD? No insurer should be allowed to make unsound judgments based on what patients confide in therapy sessions, nor should Prudential be allowed to cite every detail from patient records in denial letters when the information isn’t relevant to Plan document definitions of disability.

Clearly, Prudential insists on obtaining psychotherapy notes because it’s profitable for them to do so. Finally, using unqualified Registered Nurses to interpret the information makes Prudential’s process unfair.

Also, Prudential’s Registered Nurses aren’t qualified to practice medicine by drawing conclusions from mental health records. The only “skill” they have is enough experience to know what to “snatch” from records and how to interpret it in ways supporting Prudential’s profit agenda. A Prudential RN once told me that because there was no mention of the claimant’s “affect” in the patient notes, she couldn’t recommend paying the claim. As a consultant, I do know “crap” when I hear it!

It should also be noted that Prudential continues to utilize Unum’s old “claim killer” psychologists and psychiatrists to discredit claims, again using therapy notes to support work capacity where none exists. According to the Internet Cathy Liston, another ex-Unum VP, is Chief Operating Officer, Disability Claims at Prudential ensuring that all of UnumProvident’s bad habits are included in Prudential’s claims process.

DCS has always been opposed to the release of actual psychotherapy notes, but for a slightly different reason. Claimants who are aware that what they share with therapists will eventually wind up in the hands of insurers who write benefit checks may withhold valuable information thereby taking away the  therapeutic effects of behavioral therapy in the first place. Sharing private information during therapy sessions is the essence of therapy; therefore, why engage in therapy when claimant’s are too afraid to be completely honest?

Today mental health providers have a great dead of headway in deciding what they are willing to release and what not. Most therapists are more inclined to protect therapy notes as confidential and privileged unto themselves. Other therapists inform me they are well aware of the abuse from Prudential and other insurers that “they would never release records to insurance companies because they abuse them.”

Insureds and claimants are also more aware of their rights under HIPAA to designate some records as Private Health Information (“PHI”) and refuse to sign authorizations releasing mental health records. After all as all HIPAA authorizations inform, once released records lose their HIPAA protection.

I propose that insureds should have discussions with their mental health providers to decide for themselves how insurance requests for therapy notes are to be handled. On those occasions when therapists agree to release notes, it should be decided that each therapy session note should include mental restrictions and limitations, prognosis, and treatment plan descriptions making it perfectly clear to any outsider reviewers that the patient remains totally disabled. (Assuming that is the recommendation of the therapist.)

Therapists who make decisions NOT to release actual therapy notes can nip it in the bud very easily by informing insurers that “actual therapy notes are not released to any outside third-party.” Therapists must then also state, “however, we will provide restrictions and limitations for this patient in summary format for disability purposes.”

In my opinion, Prudential is the industry leader in misrepresentation of patient therapy notes obtained by threatening claimants and therapists with out-of-contract demands for therapy notes as “proof of claim.” That is not to say that other insurers do not do the same things, but Prudential utilizes unqualified RNs as professional psychotherapists who wrongfully assess “intent” and “malingering” by “snatching” key phrases from therapy notes that were not intended to support or deny patients’ disability claims.

Mental health awareness in the management of disability claims begins with the recognition that the disability claims review process should be fair, objective, equitable, and represent an accurate assessment of why insureds are unable to work. This is very hard to do when insurers such as Prudential deliberately “snatch” life histories and private sharing information to distort in order to bolster profitability.

Mental health claimants should have frank and open discussions with their providers to determine in advance how requests from insurers for mental health records should be handled. Certain states have laws (such as Florida) regarding the release of mental health records so it’s always a good idea to check state laws.

Prudential claimants may want to discuss insurance therapy note requests with their mental health providers very soon.

Read Full Post »

Older Posts »

%d bloggers like this: