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Archive for the ‘M&N Claims’ Category

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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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.

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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.

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Pin itMost insureds diagnosed with mental and nervous disorders are already aware that the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-5) has been published and that Global Assessment of Functioning (GAF) scores have been eliminated.

While the old DSM-IV used an AXIS I-V diagnosis description of which AXIS-V disclosed the GAF score, it was decided by the International Classification of Functioning (ICF), a division of the World Health Organization, that GAF scores were unreliable and reported only individuals’ abilities to cope with mental illness and did not relate to other health issues in general.

Therefore, the DSM-5 replaces GAF scores in favor of WHO-DAS 2.0 (World Health Organization Disability Assessment Schedule). Apparently, Section III of DSM-5 cites WHO-DAS 2.0 as the best current alternative to measuring disability.

I should point out that the World Health Organization’s input into the determination process of disability will drive conspiracy theorists crazy. Why would WHO want to clearly identify and name health issues particularly pertaining to disability? Leaving this issue for peppers to figure out, we are still left with the DSM-5 and now WHO-DAS.

The newer WHO-DAS questionnaire assesses six areas of impairment including cognition, mobility, self-care, getting along, life activities and participation. The questionnaire can be completed by individuals themselves or by clinicians, friends, relatives and other professionals such as consultants. The WHO-DAS is described as the quickest way to produce standardized disability levels and profiles, and is applicable across cultures in adult populations available in six languages.

The WHO-DAS, although tested in field clinical trials and found to be reliable, it is not yet recommended by the American Psychiatric Association until more data are available to assess its effectiveness for treatment and monitoring of disability. In particular, it’s very doubtful any disability insurers will be able to determine levels of disability from the new WHO-DAS scores. In fact, many mental health providers are receiving training in calculating the more complex weighted scores.

DCS is currently recommending to all mental health providers to include GAF scores in addition to WHO-DAS but also including a detailed explanation of what the WHO-DAS score means. It is highly unlikely that any disability insurer medical resources will be informed enough to interpret what the WHO-DAS scores mean. Therefore, we need to ask mental health providers to explain the new indicators and the severity of impairment the scores describe.

In the end, the new DSM-5 is not helpful to those with mental and nervous disorders in general. You may recall my previous posts wherein I describe the fact that many more impairments are now listed as “somaticized” or “all in one’s head”, including fibromyalgia and chronic fatigue.

Insureds may also want to know that the recent changes to DSM-5 and WHO-DAS are not alone. The  new ICD-10 billing codes go into effect in September 2015 providing a compatible identification with the DSM-5 and WHO-DAS. These changes appear to me to be gradual shifts in closely identifying mental and health issues among the adult populations of the world.

For now, it is a wise path for insureds to ask their mental health providers to explain WHO-DAS evaluations while also including GAF scores where appropriate for disability purposes. Private disability insurers just aren’t going to get it.

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DepressionAlthough today there seems to be a great deal of discussion about private disability mental and nervous claims, there is very little accurate information out there on which to make reasonable decisions for the future. While disability insurers continue to abuse the 24-month mental and nervous limitation in most policies, insureds and claimants with valid physical disabilities are harmed when seeking counseling for secondary depression and anxiety.

By definition a valid “mental and nervous” disability claim results from a diagnosis listed in the DSM-IV (V) that now classifies most impairments diagnosed clinically (without objective evidence) as “somataform”, imagined or “all in one’s head.” Since nearly all employer ERISA policies contain a provision limiting benefits to 24 months for claims resulting from mental nervous disorders and insurers continue to abuse the provision by alleging claimants are NOT physically disabled.

The conflict of interest, of course, is the fact that when Unum or any other disability insurer codes a M&N claim, financial reserves are significantly reduced avoiding the liability for claims potentially to age 65. Any insurer looking to reduce its Balance Sheet liabilities and increase profitability will investigate claims to determine if the M&N 24 month limitation is justified. Unfortunately, whether it is justified or not, many insurers deny claims under the 24 month limitation for profitability sake.

To deliberately assert a physical impairment is really “mental” for the purposes of denying benefits after 24 months is an unfair pattern of practice. UnumProvident was cited and fined by the California Settlement Agreement for abusing M&N provisions and backdating mental disabilities so that claims could be closed in less time. Although both the Multi-state and California agreements both criticized UnumProvident for their unfair claims practices in this area, it is apparent the company is accomplishing the same thing by adopting other strategies, such as using SSDI files against claimants.

In the past, it wasn’t by accident UnumProvident’s “impairment focused” review process included a “psyche-cardiac unit”. At first glance one might ask, “Why review mental and nervous and cardiac claims in the same unit?” The answer is quite simple and explains why so many physical claims are denied citing mental disorder as the reason.

Long-term and catastrophic disability often causes depression and anxiety that is considered a normal secondary impairment due to physical disease. CABG (coronary artery by-pass graft) and heart transplant patients often suffer from periods of depression subsequent to open heart surgery. Unum’s tact was to say a CABG x 5 patient had 12 weeks to recover from surgery (using their desktop medical software), but if he/she was in counseling beyond the 12 weeks, the claim was Mental and Nervous. Benefits were denied after 24 months even when the claimant suffered from severe complications. Clever.

According to an article in Psychology Today, “Bad News: DSM 5 Refuses to Correct Somatic Symptom Disorder”, by Allen Frances, M.D., the DSM V “will mislabel 1 in 6 people with cancer and heart disease; 1 in 4 with irritable bowel and fibromyalgia; and 1 in 14 who are not even medically ill.” The article basically concludes the American Psychiatric Association “has proven itself incompetent to produce a safe and scientifically sound diagnostic system. The sad result will be the mislabeling of potentially millions of people with a fake mental disorder that is unsupported by science and life in the face of common sense.”

History tells us we cannot presume disability insurers will use “common sense” to determine M&N issues, but will apply the DSM-V to their own advantage to deny more and more claims. Although most insurers use the DSM-V as back-up for the classification of mental and nervous disorders, new strategies have emerged that “stack the deck” even more against claimants with self-reported physical impairments such as migraines, chronic pain, fibromyalgia, chronic fatigue and RSD.

It makes me wonder how much influence the insurance lobby had on the American Psychiatric Association to keep certain impairments as SSDs (Somatic Symptom Disorders). Clearly, the insurance industry has always had a financial conflict of interest to limit benefits to 24 months.

In the meantime, companies such as Unum, Prudential, CIGNA, Aetna etc. have developed strategies I refer to as “aids to credibility” such as requesting SSDI files including Form 831 listing impairment codes under which benefits were SSA approved. Unfortunately, state insurance regulators have “bought into” the idea that insurers request SSDI files for the claimant’s own good and that additional information is taken into consideration.

Sleuthing out secondary diagnoses for mental disorders from SSDI awards and then alleging (according to is own opinion) depression and anxiety is the primary cause of disability has been a major Unum strategy for quite some time. Giving lip service to “we want to give your claim every possible consideration” is no more than a ruse for “we want your SSDI file to see if depression and anxiety was the primary reason you received benefits.”

Those who are legitimately impaired due to mental and nervous disorders should apply for SSDI as soon as possible since private disability benefits are likely to end after 24 months even though they are still disabled and cannot return to work. Unfortunately, the M&N provision limiting benefits for mental and nervous disorders is one of the “take backs” or adverse provisions written into ERISA group disability policies (and some DI policies) and claimants should be aware of the limitation at the time benefits are applied for.

The truth is, however, that private disability insurers are very clever in creating strategies to allege claims are due to mental disorders for the purpose of bolstering profitability. These same strategies are cloaked by the insurance industry and hide in plain sight as credible actions to “assist claimants” when in fact, insurance companies are “setting up” insureds and claimants for unjustified limitations of benefits.

DSM-V and the refusal of the American Psychiatric Association to correct classification of so many impairments as Somatic Symptom Disorders does not help claimants obtain benefits they are entitled to but instead classifies them as “crazy”, or “imagining symptoms” that do not exist.

To the detriment of an already unpopular segment of the insurance industry, insurers who are fined for unfair claims practices and abuse of the M&N 24-month limitation continue to bounce back and engage in the same patterns of practices over and over again without penalty.

Abuse of the M&N provision in disability policies is now an accepted strategy used by insurers to bolster profitability at the expense of physically impaired individuals.

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Sad phone calls

Consider the case of a 53-year old man diagnosed with Crohn’s disease, gastroparesis, and secondary depression and anxiety. He files a disability claim with Unum Life Insurance Company who informs him it is likely his claim will not be paid unless he enters into formal counseling for his depression. Unaware that Unum’s medical department completely rejected his Crohn’s disease as disabling, Mr. B. complies and begins counseling for his secondary depression. Mr. B.’s depression began when he found it difficult to manage pain and discomfort due to Crohn’s.

Unum also pushed its own vendor, GENEX, to assist him with his SSDI award. Again, unknowingly, Mr. B. fully accepted the services of GENEX who with one signed authorization obtained his records from Unum and filed with SSA on his behalf. Mr. B. does not recall signing or approving any application forms GENEX completed and sent to SSA. Acting as representatives of Unum, GENEX submitted a claim to SSA on Mr. B.’s behalf, but only submitted medical documents in support of a mental and nervous claim. No paperwork was submitted documenting Mr. B.’s primary cause of disability – Crohn’s disease.

(By the way, GENEX representatives are no longer only attorneys but paralegals. Threats by Unum not to allow the 25% deduction from overpayments for attorney fees if GENEX is not used is an unfair trade practice.)

Mr. B. was awarded SSDI for mental and nervous disability, and Unum informed Mr. B. the company would pay benefits for only 24 months. When Mr. B. reminded Unum of his primary physical diagnoses Unum replied, “But SSA also awarded you for mental and nervous reasons and we agree with it.”

Do you get the impression that Mr. B. was set-up, not only by Unum but by GENEX as well? Of course, GENEX applied for a mental and nervous claim only to benefit Unum in the payment of benefits for only 24 months. Although GENEX may be scratching Unum’s back, it is still required to submit all information regarding Mr. B.’s medical impairments.

Although Mr. B. will no doubt attempt to prove his primary diagnosis is “physical” and not mental, Unum is allowed to pull the SSDI card out of its pocket and allege that since SSA awarded on the basis of a mental and nervous claim, they can limit benefits to 24 months under the mental and nervous provision. When a set-up looks like a duck, quacks like a duck and walks like a duck, it’s probably a duck……….

When I asked this insured, “What did you think would happen when you began therapy (as Unum requested you do), and used GENEX to help you with your SSDI?”, the insured responded, “I just didn’t know.”

My observations of this claim situation are twofold. First, neither Unum nor any other insurance company can compel claimants to seek specific treatment under threat of non-payment or termination of claim. The only reason why claimants should seek specific treatment, including for mental health issues, is upon the recommendation of a treating physician to a patient who also agrees the treatment is necessary. Insurance companies could actually kill people by recommending treatment based only on paper reviews without actual face-to-face treatment history. IME physicians, who also lack treatment history with claimants, should never recommend specific medical treatment.

Second, whether GENEX set-up this insured to benefit Unum, we’ll never really know, but it’s reasonable to assume from the situation that it did.

Previous posts on Lindanee’s Blog informed the public of Unum’s abuse of M&N claims which again is consistent with Mr. B.’s case. DCS, Inc never recommends to anyone that claimants use GENEX or any other company such as ALLSUP to assist with SSDI applications. SSA determines and regulates fees and therefore all advocates (attorney and non-attorney) get paid in the same way. Furthermore, there is an advantage to retaining SSDI attorneys in particular counties and localities because they know the Administrative Law Judges and are able to work well with them. Claimants will probably pay 25% of SSA’s retroactive award regardless of who the advocate is; therefore, it may as well be a local attorney.

If claimants look carefully at the GENEX Authorization it says you cannot hold GENEX legally accountable if things go wrong. Furthermore, because of GENEX’s connection to Unum it will have access to patient records and other documents provided to Unum. What GENEX knows, Unum will know two seconds later. Claimants are always recommended to find local SSDI attorneys to handle their applications since they are all equally good.

Mr. B.’s situation is terrible. Where does he go from here? His “not knowing” caused him to shoot himself in the foot. Yes, he can appeal Unum’s decision to pay his claim for only 24 months, but now he has a powerful piece of evidence against him in that SSA awarded benefits for a mental and nervous condition.

Due to the current positions of state regulators (as described in a prior post) requiring insurers to obtain SSDI files, it has become more and more necessary for insureds and their SSDI attorneys to make sure SSA is aware of PHYSICAL causes of disability and to make sure secondary depression and anxiety is documented as just that – SECONDARY TO PHYSICAL DISEASE, or not considered by SSA at all. (This assumes, of course, that there is no real mental or nervous condition causing permanent disability.)

This is why Unum is so interested in SSA Form 831 because it lists diagnosis codes and gives the name of the DDS who made the decision to pay or not pay the claim.

Two days ago Lindanee’s Blog received nearly 1,000 reads in one day. The purpose of the Blog is to provide insureds and claimants with equal information to that of insurers who evaluate and review claims.

In today’s insurance environment, “not knowing” can come back to bite you. Although it may be too late for Mr. B., I can only hope that those who read this blog are better armed with information that can assist them as they work through a very complex and often dishonest process.

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