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Archive for the ‘Q&A’ Category

Friday Q & A

What is Unum’s internal policy regarding the management of mental health claims?

Unfortunately, Unum’s internal management of mental health claims has progressed from DSM-5 listings to declaring other impairments, such as cognitive deficits, Lyme disease, and chronic pain as “self-reported”, or “subjective”. As a result many other physical diagnoses are limited to 24 months just because Unum says so.

Unum’s abuse of the Mental and Nervous provisions in its Plans and policies is no surprise, particularly to regulators in California. From 2004-2008 regulators attempted to hold Unum accountable for M&N claim abuse, but it looks like Unum has resurrected closing down claims anytime it alleges claimed disabilities are “self-reported.”

“Self-reported” is defined as any claimed impairment for which there is no objective evidence test or lab process to verify what you say you have. “Clinical diagnosis” means patients are diagnosed with a disease based on their physicians’ history of consultation and personal observation.

Unum’s internal process is to initially approve mental health claims for depression, anxiety, panic attacks etc. for a period of 12 months. After 12 months all hell breaks loose as Unum begins to question “why” insureds are not getting better. Surveillance, field visits and IMEs in the form of neuropsyche tests are requested in an effort to discredit M&N claims after 12 months.

Let’s not forget that Unum will relentlessly continue to request actual psychotherapy notes in order to “snatch” key phrases from what would otherwise be classified as personal and private information. Most mental health providers are now refusing to release treatment notes since they are not written, nor are they intended to support or not support disability claims.

To the extent Unum can, it will continue to allege that other impairments are self-reported to limit benefits to 24 months. In some cases insureds are not capable of mentally managing Unum’s abuse and should seek assistance.

My Unum check is late. What should I do?

Unum is the only insurance company that seems to have a problem with late checks over the holidays. Most of Unum’s staff take their PTO time and “forget” to approve payments due before they leave. This is the one and only time when I recommend a phone call to customer service inquiring, “Can you please tell me when I can expect to receive my check?” Do NOT say, “Why am I not getting my check?” Just ask when you can expect it!

As I said, no other insurance company deprives its insureds of benefits during the holidays. If you check is late, call and find out when you can expect to receive it.

I’ve sent medical records three times to Unum. It still says it hasn’t received them. Now what?”

I know. Apparently, Unum Group is now as inefficient as Aetna, and CIGNA when it comes to losing and misplacing documentation it receives. I’ve discovered myself that Unum’s claims handlers have absolutely no idea what is and what isn’t in the claim files. Multiple requests for the same information are sent out to insureds who are required to re-send valuable information. Physicians are becoming more and more wary of accepting patients with disability claims because of Unum’s direct harassment that never ends.

Claimants who send their own information should send by either Priority Mail or Priority Mail Express with Signature Confirmation. (What is amazing is that Unum never seems to lose records sent this way.) If faxing, always print out a paper confirmation that records were confirmed received.

Unum used to have much more control over its administrative process but in the last year or so it has been lowered to Aetna’s and CIGNA’s chaotic system of claim review. Unum’s claims review process is negligent at best, another thing the company should not be proud of.

My Unum claims handler doesn’t seem to know very much. Should I be worried?

Several things are in play here. Unum continues to engage in gender and age discrimination to the point that tenured and experienced employees are frequently fired. New, younger, and alleged healthier individuals replace knowledgeable claims staff.

New U-numbies are essentially 1 French fry short of a Happy Meal in terms of understanding “risk management” and the adjudication of disability contracts. In addition, new claims handlers are deliberately dumbed-down to not know anything other than doing what they are told. Remember, it’s Unum’s way or the highway, allowing more and more fry less Happy Meals to touch claims.

My recommendation is to make sure you are communicating with Unum only in writing so that its poor service and “stupidity” can be documented for the record. Actually, this is true for every disability insurer in the country.

 

 

 

 

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Friday Q & A On Monday

Can I resign from my job and go out on disability?

DCS, Inc. receives on average 5-6 inquires per week questioning whether it is a good thing to “resign” from jobs to go out on disability. There is actually a very good post already on this blog that is the number one “hit” by readers. However, I’ll try to answer the question again briefly.

DO NOT RESIGN. There is a huge difference between “going out on disability” and “resigning”, which means “I quit.” If your physician recommends a period of total or partial disability, you are not “quitting your job”, but acting upon the direction of a primary care physician for medical reasons In addition to your eligibility for STD/LTD benefits you are subject to FMLA that protects your job and benefits for 12 weeks. If you are unable to return to work after 12 weeks, your employer can terminate you and stop paying for your health care, pension and other benefits.

Also, quitting your job may prevent you from obtaining unemployment. Therefore, you should NOT provide your employer with a letter of resignation, but rather a letter that requests STD/LTD forms for benefits you are entitled to, and perhaps a sentence that says, “Based on the recommendation and medical restrictions and limitations of my physician(s), I will cease work on [date], and will be medically considered to be totally disabled until further notice.” Notice the word “resignation” is no where in the letter.

Remember, “resign” means “I quit” and that’s not what you are doing when you need to leave work due to disability.

Are Fibromyalgia and Chronic Fatigue claims paid these days?

Thanks to the DSM-5 both FMS and CFS are classified in a new category of “Somatoform Disorder Syndromes”. Most insurance companies now follow the new DSM-5 in classifying these disorders as mental and nervous, limiting benefits to 24 months. In addition, it’s also easier to allege FMS and CFS are self-reported and also limit benefits.

Furthermore, rheumatologists are more inclined to also follow the direction of the new diagnostic manual by refusing to certify total disability for FMS or FMS-like symptoms. And, by the way, DCS. has a new strategy for assisting FMS and CFS patients who apply for disability that could be quite helpful. Nevertheless, disability insurers have finally persuaded the DSM-5 that FMS, CFS and many other former syndromes are literally “all in your head.”

Does Social Security conduct surveillance?

Recent information seems to suggest that the agency does conduct surveillance but only in cases of suspected fraud. Most of the fraud cases reported to SSA come from  vindictive spouses and disgruntled neighbors. Therefore, there is nothing to fear from SSA surveillance if your submitted claim is truthful.

How do I know I’m ready to go back to work after a period of disability?

There are several very good articles on the blog about returning to work. However, I recommend that you engage in a voluntary, unpaid “work hardening” program prior to actually returning to work on a permanent basis.  Please feel free to give me a call to discuss if this subject if of interest to you, or search the blog for the full articles.

 

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Friday Q & A

Unum discontinued my AIDS disability. That’s a pretty crappy thing to do. What do I do now?

Unum seems to have an ongoing bias toward HIV and AIDS, it always has.The company takes the position that if T-Cell counts are 200 and above, and Viral Load is none, individuals can return to work full-time. While the newer cocktail medications considerably extend the lifespan of HIV patients, they by no means cause other symptoms to disappear, such as chronic diarrhea, various neuropathies and severe fatigue.

The medical community considers a T-Cell count of 500 and above as “normal” but Unum attempts to allege that HIV and AIDS sufferers can work with levels as low as 200. Also, a T-Cell count of 200 still puts patients at risk for severe bacterial infections that are life threatening.

Again, Unum persistently chased after HIV claims for many years now and will likely   continue as medications continue to improve and provide better treatment for those with HIV. However, those patients who continue to suffer with chronic symptoms that preclude a return to work should appeal any denial and contact as many HIV and AIDS organizations to inform of Unum’s actions. It’s likely the HIV community will offer to put Unum’s prejudice in the court of public opinion.

What does your 401(k) and 403(b) have to do with Unum?

Absolutely nothing. Unum’s employer Plans exclude 401(k) and 403(b) employer contribution Plans from offsets. If any claims handler begins chasing this information cite the language from the Plan that excludes these two items as offsets.

I am a Unum employee and it denied my FMLA when I had to go out on STD. What now?

Unum is infamous for denying disability to its own employees. In fact, the company prefers to “make you suffer” so that you quit and the company can hire healthier employees.

One of the ways Unum throws its ill employees under the bus is to make them use up all of their PTO time first before starting STD. This means that employees who need to remain out of work, let’s say in January, will have to go without any paid time off until the following year. FMLA is always denied so that Unum managers can pad personnel files and terminate employees for “poor performance” even though absences from work are legitimately disability related.

The point is that Unum does not keep employees who need to be absent from work due to a medical disability. Unum hires young, healthy, “A” personalities to administer its claims. If you fall outside of those parameters you’re a “goner” in more ways than one.

My employer is pushing me to return to work when I can’t. What do I do?

In this instance it is very important to medically document your disability. Your physician must provide medical restrictions and limitations and state why he/she is not releasing you to work. Of course your job is only protected for 12 weeks under FMLA, therefore your employer can terminate your employment if you do not return to work after the 12 week FMLA period.

Eventually, your physician should be recommending total disability and application for LTD. Most employers will terminate employment when this happens. If you can go back to work, you should do so within the 12 week FMLA period in order to keep your job. Otherwise, you should apply for LTD and consider SSDI.

Although employers can’t force you to do anything, they can terminate your employment after 12 weeks. If you can go back to work, you should to preserve your job.


Please don’t forget my first Ebook “Settements” is available by clicking the link at the top of Lindanee’s Home Page “Ebooks”. My Ebooks are also available from my website located at: http://www.disabilityclaimssolutions.com.

I am currently working on Book 2 “Appeals” that I think most readers would find very interesting, particularly those who choose to manage claim appeals on their own without an attorney.

A third book is also planned by year-end on the subject of “Returning To Work After Disability” that includes information about preparation of resumes with missing work history. This will be an excellent guide for those with plans to return to work in the future.

Ebooks are free to DCS, Inc. clients upon request.

If you have any suggestions of topics of general interest please let me know by email:

DCS@metrocast.net

If you would like more information about becoming a DCS, Inc. client please feel free to call me at 207-793-4593.

Thanks.

 

 

 

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Friday Q & A

Can Unum, or any other insurer deny claims after SSDI is awarded?

Of course they can. In fact, Unum’s false flag of assuring you the company wants to “give your claim every possible consideration” is obviously untrue since Unum rejects SSDI information in favor of its own misrepresented medical views. It’s an interpretation of the old “bait and switch” marketing ploy. Unum presents its intent as honorable while the real interest in SSDI information is to discover Form 831 information it can use to deny claims such as mental and nervous listing approvals.

In addition, once Unum has claimants believing SSDI information will help them, claims are still denied but this time the company says, “We considered information from your SSDI file but we have more current information that Social Security didn’t have at the time you were awarded”, hinting that perhaps you shouldn’t have been awarded SSDI in the first place.

As I’ve said many times on this blog, disability insurance and SSDI is the most infamous estoppel there is since insurers first force claimants to apply and then they use the information to deny claims (not to mention that insurers take retroactive SSDI awards first).

I just read a letter from Sun Life to a claimant explaining how different their policy language is from qualification for SSDI. If this is true, then how is it their representatives can force people to apply? Either claimants are totally disabled and meet SSDI criteria, or they don’t. Which is it?

Yes, insurance companies can deny disability claims when SSDI is awarded. Not only can they do this, but most insurers have developed “safety net strategies” so that they benefit, rather than not from the process.

How do I know whether I owe Unum an overpayment when they inform me of it but won’t prove or show me the calculations?

I am unfortunately aware that this is going on at Unum; and, I suspicion it’s the involvement of Lucens who is most likely financially reviewing claims looking for the $1-$2 overpayments due to miscalculations. It should be somewhat troubling if not suspicious to insurance regulators that there are so many “mistakes and errors” suddenly uncovered.

There are many people receiving “overpayment” letters ranging from $60 overpayments to into the tens of thousands. Doesn’t it seem odd that a company like Unum would have made so many calculation errors that need to be corrected? In addition, letters are going out to insureds and claimants that errors have been discovered and deductions will be made from benefits.

There is no effort on the part of Unum to provide copies of the actual calculations, prove or validate that any amount is actually owed. Therefore, before anything is paid back DCS, Inc. is recommending that insureds and claimants notify Unum in writing they wish to receive proof that the overpayment is actually owed. This would include spreadsheet calculations, or any financial data relied upon by Unum to allege additional monies are owed.

ERISA folks can actually appeal Unum’s overpayment allegations and request disclosure proof be provided prior to offsetting benefits. In today’s business environment it is astounding to me that any insurance company would presume to get away with “taking money from benefits” without first proving it was owed. In what other business would a customer actually give up money for a debt that is not proven?

It also should go without saying that anyone who actually believes what Unum says about anything should come to Maine and buy some marsh swamp land developers have for sale.

Unum is sufficiently discredited in the public’s view that it is reasonable for all insureds and claimants to insist on seeing the actual calculations before agreeing to reduce benefits for an “alleged” overpayment.

Unum’s say-so, should essentially be a no-go.

 

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Friday Q & A

Can Unum send a representative to my house?

What you are referring to is called a field representative visit, and “yes” they do ask to visit you in your home. HOWEVER, you don’t have to allow the reps into your home at all.

If your policy requires you to submit to a field visit, you may ask to meet with the representative at a public place such as MacDonald’s, Wendy’s or a local coffee shop. The purpose of Unum’s asking to meet you in your home is to enable you to “talk” and “feel more comfortable”  potentially sharing information Unum has no right to ask, or know.

Visits allowed to take place at home usually last a great deal longer, such as two-three hours while visits in public places only last for about an hour. The field investigator is a professional profiler who writes in his/her report about your home, how you are living.

When I went to “Unum school” years ago, the instructor, and head of SIU (Special Investigations Unit), described various means of “trickery”.

For example, on the day of the visit in her home one insured described how she had to use a cane to walk all the time and had also placed a very conspicuous cane leaning against her table. During the interview, the Unum investigator asked for a drink of water and the insured walked up three steps to the kitchen to get it, forgetting her cane.

Another example included an insured who was alleging he had severe cognitive issues and couldn’t take care of his finances. The rep pulled out all of the change he had in his pockets and asked the insured to count it, which he did perfectly. Oops!

DCS, Inc. does not recommend field visits take place in anyone’s home for all of the above reasons. There are several other posts on Lindanee’s blog dealing with field representative visits. If you search from the home page you will find more details on the subject.

Are we allowed to see what Unum’s investigator’s write?

No. You may have access to the report after your claim is denied which is something you do not want to happen. Northwestern Mutual will send out a synopsis, but it isn’t the same report that goes into the record. ERISA insureds aren’t entitled to see anything in the Administrative Record until the claim is denied. IDI insureds have no right to disclosure and insurers may or may not send copies of the file at the time of termination.

What does ERISA have to do with pre-existing conditions?

The answer is quite simple – nothing. Group Plans and policies contain provisions that describe under what circumstances claims would be considered pre-existing. Although there are many types of pre-existing conditions, ERISA doesn’t deal with the issue directly, or more so than any other provision in the policy.

The courts have considerable influence over what is and isn’t a pre-existing condition.

Can Unum deny STD benefits?

Of course they can, and do, on a regular basis.

In the past STD was viewed as a “sure thing” since no financial reserve was required for that line of business. However, Unum’s management is now aggressively managing STD and denying more claims than ever. Unum’s motto? “Deny sooner rather than later.” It’s generally accepted at Unum that it’s better to deny the shorter 26 week STD claims sooner rather than to inherit the more expensive LTD liability to age 65.

 

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Friday Q & A

I’ve had many very interesting questions submitted to DCS this week. Thanks to everyone who submits questions that are most likely important to others as well. Since my readers are too fearful to provide support to each other via the comment section, I like to answer questions here as Q & A. If you have a question you’d like answered, please send me an email.

What are some of the things I need to know about Unum?

WOW! What a question. I’ll try to list a few for you here:

  •  As the renamed company of Unum Life Insurance and UNUMProvident, Unum Group has a history of unfair claims practices that can be verified by the Multi-State Settlement Agreement, Georgia Conduct Market Examination and the California Settlement Agreement.
  • Through its claims management, Unum deliberately targets specific claims and then “works” them through their internal claims review process with deliberate intent to deny at some future date.
  • Unum relies solely on internal medical reviews (including insurance defense outsourcing) as back-up for denials. Medical information submitted by insureds and claimants is omitted from consideration. The company also has a hierarchy of medical review that creates the “illusion” of credibility. Unum systematically stacks the deck against insureds by “snatching” certain key phrases in patient notes and records favorable to them, while ignoring all else in the record favorable to insureds.
  • Unum misrepresents policy Plan and contact provisions, and is often dishonest in other ways.

Although I could probably fill a book with details about Unum Group, please let me recommend that you Search the Blog for additional topics and you will find out plenty of detail.

How is appropriate care determined?

Typically, treating physicians dictate what “appropriate care” is based on their previous history of consultation and treatment with their patient insureds, although it is very rarely documented as “appropriate care” in the records. Most insurance companies accept that fact except for Unum.

On occasion I’ve seen Unum cases where it sends out threatening letters to insureds informing them that if they don’t get into certain care, claims will be denied. A good example is a claim where the insured was diagnosed with meningitis and encephalitis who now has residual symptoms of cognitive deficit. Unum threatened this insured that if he didn’t get into mental health treatment and counseling Unum would deny the claim at 24 months.

Clearly, the cause of disability was physical in nature and not subject to the 24 month mental and nervous limitation and yet Unum determined “appropriate” care to be behavioral requiring counseling therapy. DCS, Inc. assisted this insured in proving to Unum that it’s determination of “appropriate care” was inappropriate, and we were successful.

It’s important to remember that TREATING PHYSICIANS determine what is medically appropriate within the recommended guidelines of the medical community. An example of inappropriate care would be a person diagnosed with depression and anxiety being treated by a family physician; or, treatment outside the specialty of the claimed impairment.

If your physician fails to document what he/she recommends as “appropriate care” you can be sure the insurance company will, particularly Unum.

DMS is making a request for an IME. How does DMS work?

Disability Management Services, Inc. is a reinsurer who buys up blocks of business and assumes the risk of other insurance companies.

By definition, DMS isn’t really an insurance company itself, but more like a corporate holding company who buys up other businesses, put minimal money into them, and then sells them at a profit. State departments of insurance do not recognize DMS as an insurance company and complaints are usually handled with responses of, “we have no jurisdiction.”

There are only two possible outcomes for claims managed by DMS. Either the claim is paid and IME’d to death until it can be denied, or the claim is “settled”.  Again, reinsurers by definition won’t pay claims indefinitely so those insureds who think DMS will continually pay claims without problems are very mistaken.

In one year, DMS requested one of my clients submit to 5 separate IMEs that kept coming back in her favor. Finally, after two years my client agreed to a lump sum settlement in order to have some peace.

DMS will NEVER stop requesting outside evaluations until a report finally shows up in its favor. It is very important for insureds to recognize the goals and objectives of reinsurers as different from regular private disability insurers.  Claims handlers are far more aggressive as well.

Can I really sign away my ERISA rights?

This question reminds me of occasions when Unum used to send out letters asking claimants to “sign below” waiving ERISA timelines for appeal review. It would be very unwise for anyone to sign such a waiver.

It’s egregious for Unum to ask you to give your permission to waive ERISA timelines and I never recommend doing it.


ebooksPlease don’t forget my first Ebook “Settements” is available by clicking the link at the top of Lindanee’s Home Page “Ebooks”. My Ebooks are also available from my website located at: http://www.disabilityclaimssolutions.com.

I am currently working on Book 2 “Appeals” that I think most readers would find very interesting, particularly those who choose to manage claim appeals on their own without an attorney.

A third book is also planned by year-end on the subject of “Returning To Work After Disability” that includes information about preparation of resumes with missing work history. This will be an excellent guide for those with plans to return to work in the future.

Ebooks are free to DCS, Inc. clients upon request.

If you have any suggestions of topics of general interest please let me know by email:

DCS@metrocast.net

If you would like more information about becoming a DCS, Inc. client please feel free to call me at 207-793-4593.

Thanks.

 

 

 

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Friday Q & A

Can a person be denied health insurance or reimbursement for treatment of fibromyalgia and chronic fatigue?

While there are so many different versions of health insurance available the short answer to this question is that health insureds are entitled, or not entitled, to whatever the health insurance policy says they are entitled to.

I don’t think it’s unreasonable to say that most people don’t actually read their health insurance policies. However, everyone should make an effort to obtain and read their actual health insurance Plans so that there are no surprises in the future when emergencies occur. It is entirely possible that some health insurance policies may not cover FMS or CFS,  limits reimbursement for treatment, or increases co-pays.

The best pre-emptive solution to insurance problems these days, including health insurance, is to be a good consumer of insurance products by reading the policy before purchasing it and having a thorough understanding of what’s covered and what isn’t.

What is Unum’s Navilink?

Navilink is Unum’s internal diary system. In theory it is a type of SOAP NOTE diary system whereby all activities taken on a claim can be documented. However, if you actually read the Navilink entries you will see that there are quite a few blanks left in the claim program.

At one time Unum Life Insurance was a stickler for documentation. I can remember management telling the claims handlers: “If it isn’t documented in the file, it didn’t happen.” Some Unum managers actually taught their newbies that one should be able to pick  up any file and have a complete record of everything that took place in the review process.

Eventually, Unum’s management realized this kind of detailed documentation was discoverable shot Unum in the foot at the time of the Multi-State Settlement Agreement investigations, and management decided to advise claims handlers not to go over board with claim documentation.

Therefore, while Navilink seems to keep claim activities organized internally, the notes rarely assist attorneys and Plaintiffs with information of wrong doing – intentionally, of course. The same is true of Unum’s Benefit Manual that describes separate processes but does not explain how a claim is reviewed from Step 1 through resolution.

Navilink does keep track of phone calls, and basic review information but it is not the whole story of what goes on in the claims process. Just try to find details about a “roundtable presentation”, or who attended Team meetings and what the outcome was. This information is NOT documented in Navilink, nor is any other information that could be viewed adversely against the company.

While Navilink might be a good way to keep information organized internally it shouldn’t be regarded as a complete record of activities taken on claims. It isn’t.

Should I play golf when I’m receiving SSDI?

Oh boy. Here we go again.

It depends on what you and your doctors are reporting to SSA, or your disability insurer as to what your restrictions and limitations are and why you can’t work. As a disability consultant I’m of the opinion that there are very few insureds who would be able to play golf after alleging total disability, or if they were able to play golf probably have at least some work capacity.

Working is both physically and mentally healthy, and anyone who has work capacity should be working, not playing golf.

The physical activity of playing golf involves arms, legs, hands, shoulders, trunk and back, weight-bearing capacity, lifting, walking, stamina (even if you use a cart), and mental capacity to figure out all the variables (terrain, wind, slope) and recording an accurate score at the end.

I wouldn’t want to be the one to have to explain to an insurance company how I am able to play golf but can’t work because I have chronic pain, back pain, carpal tunnel, fatigue, muscle weakness, lack of physical stamina, keeping me from working. Insurance companies generally regard anyone who can play golf as having work capacity.

Several years ago there was a disability case of a semi-pro female golfer alleging FMS kept her from working and yet she played in a pro-tournament. Unum denied her claim, and probably rightfully so. Another insured claimed a Unum disability for back trouble but took a part-time job as a ski instructor. Unum denied that claim too!

Finally, CIGNA caught a claimant with chronic pain engaging in motor cross bike tournaments and denied his claim when he bragged about it on his FB page.

Whether it’s private disability or SSDI insureds should abide by the medical restrictions and limitations provided by their physicians and reported to insurers. If you can’t work due to a set of physical R&Ls chances are you can’t play golf, ski or do motor cross racing either. It’s just common sense.

 

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