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Archive for the ‘Q&A’ Category

Friday Q & A

What is Life Waiver of Premium?

LWOP is a provision in most life insurance policies that waive payment of life insurance premium when insureds are determined to be disabled from performing ANY occupation.

For example, if you have been approved by Unum for benefits beyond 24 months, AND you have a life insurance policy by, let’s say, Mutual of Omaha that contains a Life Waiver of Premium provision, you should contact MofO and submit paperwork so that your premium for life insurance can be waived.

There is also a provision in most disability policies that waives disability premium while the insured is disabled. To be sure, you need to check your life and disability insurance policies to determine what premium can be waived and when.

It is important to note that LWOP and disability premium is only approved when insureds are determined to be totally disabled from ANY occupation, a much higher burden of proof than just disabled from performing one’s own occupation.

Does Unum Discriminate Against Insureds Over 65?

Yes, but in a way you may not realize. For insureds with IDI polices that pay Lifetime Benefits under certain conditions, (Accident vs. Sickness), Unum has several tricks up its sleeve to NOT pay Lifetime Benefits.

Dates of disability are extremely important since most policies define Lifetime benefits in terms of “at what age claims are filed.” For example, if disability is filed before the age of 60, the policy pays Lifetime benefits. If over sixty, benefits will be paid only to age 65. Unum does everything within its power to refuse earlier dates of disability, particularly for Accident claims prior to the age of 60 where Lifetime benefits are indicated.

What most insureds with IDI policies don’t realize is that IDI policies DO NOT STAY IN FORCE beyond the age of 65 unless the insured returns to work full-time. Although there are several versions of guaranteed insurability, in general, at some advanced age insureds must return to work full-time in order to keep their policies in force.

As a matter of protection, it may be advantageous to pay the extra premium for both Accident and Sickness Lifetime Riders that makes Unum’s bad faith to deny benefits much harder to pull off.

This does not mean benefits for a prior claim cease at age 65, but it is a contractual condition indicating a return to full-time work is required in order to keep the policy in force after some advanced age.

Any IDI policy can go away at an advanced age while paying a prior Lifetime claim.

What is an ATP when referenced with a STD claim?

Employers have a choice to “self-insure” or “fully insure” Short-Term Disability (STD). This means employers can actually fund their own STD, or buy STD Plans from Group insurers who pay benefits from a separate Group STD Plan.

Employers who choose to “self-insure” their own STD Plans, generally hire the same Group insurers as ‘Third Party Administrators” (TPA) who investigate STD claims and render “Advice To Pay” (ATP) back to the employer.

Although employers choose to pay their own company-paid STD, managing and reviewing claims is NOT something most employers want to become involved with. Therefore, employers typically hire TPAs who render ATP back to the employer. I know insurance jargon can be confusing, but I’m finding more and more employers are actually self-insuring STD investigated by third-party administrators.

LTD is rarely self-insured.

Can Unum Offset SSDI COLA?

Generally “No”, but check your own Plans to be sure.

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Friday Q & A

Allsup is requiring me to let them get into my checking account. I don’t think this is  a good idea. What do you think?

To begin, DCS, Inc. doesn’t recommend clients, (or anyone else), use Allsup for SSDI assistance. Although most insurers also suggest giving them access to bank accounts, it is never a good idea to do so.

In fact, most insurers are either asking for access, or arbitrarily including the permissions in their authorizations, which you may not notice if you don’t read the Authorization. Never give any insurance company access to financial accounts. Frankly, insurers make far too many mistakes to trust that they wouldn’t $0 out your personal accounts by mistake.

Beyond this, I don’t recommend Allsup for SSDI assistance, much less being able to access personal banking accounts. This also goes for GENEX and Advocator Group.

Are IME Addenda a good thing?

Actually….no.

Some IME physicians’ reports are written in a way that both appeases insurers with an agenda to deny claims, AND medical ethics with a phenomena I call “sitting on the fence.” From the insurance company’s point of view, having an IME physician “sit on the fence” does not provide sufficient proof to deny claims. When this happens, insurers will go back to the IME physician with more specific questions to encourage IME physicians to be more precise in their reports.

The important thing for insureds to know is that when IME reports are forwarded to treating physicians or attorneys, they should make sure any existing addendum and responses are also included. Even attorneys make the mistake of not following up with requests for any “addenda” and only find out about it when litigation begins.

Another way to describe requests for IME addendum is “putting words in the IME physician’s mouth.” Care and follow-up need to take place to make sure insureds and their representatives have the opportunity to review the addendum as well as the original IME report.

The fortunate thing is that some IME physicians respond to addendum requests by still “sitting on the fence.” When this happens either a second IME will be requested, or claims will continue to be paid.

Can I quit my job while on disability?

This question seems to come up a lot.  No one quits…..NO ONE QUITS when it is necessary to stop working due to a disability. “Quitting” means that you make a decision to stop working even when not disabled. If your physician provides you with medical restrictions and limitations preventing you from working THAT’S NOT QUITTING, AND IT’S NOT RESIGNING!

Medical disability is entirely different from “quitting’ your job. You simply notify HR that your doctor recommends that you stop working and file for disability. You aren’t even required to explain what your disability is. Technically, you are on medical leave and if you qualify for FMLA, unpaid medical leave begins to accrue for 12 weeks, sometimes more. If you are asked to resign, you explain in a short letter that your doctor is recommending that you not work for medical reasons.

No one resigns or quits when leaving work for a medical disability. There are several good posts about the subject already on Lindanee’s Blog.

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All Insureds receiving private disability benefits have at one time received questionnaires from their insurers. Some are pretty straight forward in asking questions about the personal lives of insureds, others are multi-paged invasions of privacy that go far beyond the scope of claim investigation.

I recently had the opportunity of reviewing questionnaires from Reliance Standard, The Hartford and Unum. I observed that “Questionnaires” per se can be broken down into two major sections – legitimate update information and deceptive questions invading privacy.

While insurance companies do have the right to ask questions of an “update” nature they do NOT have the right to ask personal questions that are not work related or medically required in order to support claims. Insurers also have the right to SSDI financial information, and in the case of IDI policies, tax returns and certain other agreements. Beyond this, insurers ask questions when the answer should really be, “Mind your own business!”

Why does any insurer need to know the following:

  • How many hours do you use your computer?
  • How long do you nap? How many naps do you take?
  • Do you do your laundry?
  • Do you cook your own meals? Do you cook your family’s meals?
  • How far can you walk?
  • Do you go to Church?
  • What are your hobbies?
  • Do you garden?
  • How many times do you go to the bathroom?
  • Do you go out? Where do you go?

Some questionnaires go on and on asking personal questions about daily activities. At one time, (and I haven’t seen it for a while, thank goodness), Unum had a questionnaire asking insureds to write down all of their activities every 15  minutes. Healthy people would have a problem completing this kind of form!

Unfortunately, the first tendency of insureds is to fill up the page with as much information as they can – exactly the wrong thing to do. Somewhere along the line your sensibilities have to remind you that most of the questions are beyond the scope of claim investigation and that perhaps you don’t have to answer them. Remember, questionnaires are sent out in addition to the regular update forms, therefore, insurers are already informed of claim update information. So why the invasive questionnaires?

Insurers are well aware that insureds will do everything they can to “fill up the page” often attaching additional sheets. While the regular update forms are asking for genuine update information, questionnaires are deceptively asking about work capacity. Filling out an insurance questionnaire with writing in every space is exactly the type of information insurers use to allege you have work capacity and can return to work.

I’ve written several good blog articles about METs that you may recall. The Metabolic rate is expressed as an equivalent of the resting expenditure of energy for various physical activities. For example walking fast is 5 METs meaning the activity of walking is five times that of an average person sitting in terms of energy expended. Doing laundry is 8 METs, if downstairs in your basement, 11 METs.

Sedentary work capacity is equal to 5 METs, therefore, it doesn’ take very much activity to be able to return to work full-time in a sedentary capacity. Sometimes during cardiac rehab patients can perform up to 10-15 METs on a stress test. That’s “Light” work capacity!

Questionnaires deliberately ask questions about your daily activities in order to evaluate the total number of METs you are able to do in a day so that a conversion can be made to approximate METs performed, arriving at work capacity. An innocent mention of “I spend time with my kids” is equivalent to 10 METs and that is at least sedentary to light capacity for work.

Insurance questionnaires are always looking for self-admitted work capacity, and they do it in very deceptive ways. Insurers use fear and psychology to encourage insureds to “just fill up the page.” Frequently, insurers conduct surveillance shortly after receiving back questionnaires for the purpose of looking for “inconsistency of report.” For example, you say one thing, and surveillance observes something else. The more information you write on the questionnaire the tighter the hangman’s noose is.

“Yes” and “No” are still very good, truthful answers without all of the justification that insureds try to add in. Insureds always have the right to ask, “What does this have to do with the definition of disability in my policies?”

If you find your insurer with its nose in your business remember that everything you say on a questionnaire is converted to METs equivalent for physical work capacity. If you have difficulty filling out questionnaires, please feel free to give me a call.

 

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Friday Q & A

Is Unum Long Term Care a good product?

Unum LTC was an unprofitable flop, and in fact, the company isn’t even selling it anymore. Class action lawsuits were filed against the company by CA policyholders of LTC who charged that they were denied maximum benefits due to “flawed calculations” using inflation factors. In 2016 policyholders were awarded $46M in a settlement as reimbursement for lost LTC benefits.

In retrospect, Unum seems to always be “calculating” something. It’s current initiative I’ve dubbed “nickel and dimming”  relating to SSDI recalculations involving Lucens may turn out to be yet another “miscalculation” that’s costing ERISA claimants benefits they can’t afford to payback if they don’t legitimately owe it.

In any event, Unum isn’t selling Long-Term Care products anymore and thank goodness for that!

Can your employer make you quit and go on disability?

No, employers don’t have to “make” you do anything, they can just terminate your employment. As you may know FMLA (Family Medical Leave Act) requires employers to keep your job open and continue to pay benefits for a period of 12 weeks. Beyond that, employers can terminate you with the blessing of the federal government.

Keep in mind employers may also terminate you for “poor performance”, but generally take the softer approach and recommend that you take advantage of the company’s STD/LTD programs. Employees who can’t perform on the job but who refuse to use STD/LTD can be terminated anytime.

Although employers seem to be sympathetic with employee health concerns the sentiment can quickly change if, and when, employees are unable to return to work after a period of STD. Therefore, employers really don’t need to force you to go out on disability, they can just fire you for poor performance if you don’t apply for disability and leave work on your own.

What do you think of Unum’s “Aspire” Program?

In my opinion, Unum’s “Aspire’ program of sending highly productive adult employees to Disneyland is demeaning and insulting. The selection process is flawed by choosing claims handlers who deny the most claims. I preferred “The President’s Award”, a much more prestigious honor for employees.

If you already work for Disneyland and the wicked witch, it’s not really a great prize to visit the same place and receive even more brainwashing. Frankly, I think the program should be viewed as insulting to grown adults.

Can I play golf while on disability?

Insureds keep writing to me and asking me this same question over and over again. Golf is a very strenuous sport that involves walking, bending, stooping, stamina, physical capacity, overhead reach, and concentration. The sport requires the use of arm, shoulder, and back muscles, legs and the ability to walk distances, weight bearing etc.

My answer is “NO!” Those with disability medical restrictions and limitations severe enough to preclude working shouldn’t be playing golf in my opinion.

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Friday Q & A

Is Sun Life a Unum company?

No, it isn’t. However, as it turns out, many terminated Unum employees, including Unum’s lawyers, eventually wind up hired by Sun Life. The same situation exists between Unum and Prudential. This is why both Sun Life and Prudential have very similar Unum claims practices.

In like manner, I find The Hartford also has very similar claims practices because management from the old Unum Duncanson & Holt must be hanging around. There is no doubt but that Unum Life, UnumProvident and now Unum Group are writing the script for many other insurers. If you look at the written communications much of the same language is used.

The Hartford is now requesting copies of SSDI files and financial data, a clear copy from Lucens and Unum.

Does Unum pay claims?

Of course it does, but clearly not at the 80% rate it advertises. All insurance companies pay claims, but all insurance companies also “risk manage” the rate they pay claims in order to show company profit at certain levels. Unfortunately, this means targeting legitimate, payable claims for denial in order to keep the LARs (Liability Acceptance Rates) low, consistent with the 60% underwriting payout used to cost premium.

More realistic estimates of Unum’s payout rate would be around 30-40 percent.

How long does it take to sue Unum?

Assuming attorneys do not “settle” claims, which seems to be the  preferred action these days, it can take years to sue any insurance company for private disability. No one should be looking to sue for private disability since even if claims are won, it’s the attorneys who walk away with most of the benefit. In some cases, ERISA benefits to claimants are actually reduced to less than 30% of pre-disability earnings.

The smarter thing to do is to avoid denial by listening and acting upon good advice.

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Friday Q & A

Has Unum ever been fined for HIPAA violations?

No. Disability insurers are specifically named in the law as exempt as “covered entities”. However, physicians are NOT exempt. Since medical records and information often flows from physicians to Unum, the handling of records electronically by physicians could be a violation. Although Unum’s Authorizations mention HIPAA, it does so to protect the flow of medical records from company to physician, and to IME physicians I might add. Most people are unaware that HIPAA only protects the “electronic” submission of patient health records.

I have often wondered why some treating physicians are so eager to speak with Unum docs on the phone. Patient information shared “electronically” is, of course, the focus of HIPAA. Clearly communications on the phone are “electronic”; physicians who continue to take calls from insurers probably need to pay more attention.

Unum’s offenses here are violations of “Privacy”, not HIPAA. I once found a tax return for one insured in a file for someone else. A paper file was dropped on Congress Street and documents went everywhere….Such practices do not happen often now due to technologic transitions to online sharing.

In any event, if you look up HIPAA on the Internet you will see that disability insurers are named as exempt from compliance with HIPAA.

Should I sue Unum pro se if I can’t afford an attorney?

No. Nada. Nope. Never. No way. Not in your lifetime. Forget it. Impossible. Foolish…..

Insureds/claimants are not prepared to come up against attorneys who are deceitful and who do not play nice. In fact, in my 85 Unum cases and depositions I came up against the Unum mafia, and one Unum attorney who I’m sure was bat poop crazy. Claimants cannot imagine the unethical disrespect they will receive from Unum’s legal team, not to mention the fact that both ERISA and state law requires more knowledge, such as that from an attorney.

DCS, Inc. never recommended pro se representation by insured lay persons and still doesn’t. Given the current climate and temperament of private disability insurance, pro se isn’t a winnable option.

Robert Crispin

For some reason DCS, Inc. received several inquiries this week about Robert Crispin, a former Unum Executive, albeit so briefly. I wrote an excellent article, Blast from the Past: Whatever Happened to Robert Crispin? (3/18/2013) If you are interested in this very covertly held Unum Executive please do a search on this blog and read the article. It is a very interesting story.

I felt sorry for Bob Crispin. He seemed to get pulled into a situation until Harold Chandler stole his cheese. Interesting Unum history.

Does my employer have a say on my LTD decision made by Unum?

Yes, and no. Technically, Unum is a co-fiduciary with the Plan Administrator – Unum. For ERISA Plans, the Plan Administrator is given the authority to make decisions on claims. IDI policies, of course, have no employer involvement.

HOWEVER, by its very nature, Group Coverage can be cancelled or changed each year during the employer’s annual enrollment. Employers insuring over 2,000 lives is referred to as a “national account” that brings in quite a bit of income to Unum. Employers who threaten to take their business of 2,000 lives somewhere else generally get what they want. Even Unum recognizes it’s cheaper to pay the benefit of a particular claimant in dispute than lose the business of a “national account.” I’ve seen this happen several times when I worked for the company.

I think it’s also important to mention that group STD/LTD employers have no vested interest in paying claims any more than Unum does. Every employee who goes out on disability increases the “experience rating” of the group. Although a benefit of group insurance is that the underwriting is “of the group”, not the individual, there is underwriting that takes place nonetheless, and premium is increased to reflect the numbers of the covered group that leave work on disability.

This question was asked only about LTD, but employers can have a great deal of influence with self-insured STD evaluated by third-party administrators. Since benefits are actually paid by employers, they can override Unum’s decision on STD and pay the claim anyway. Whether employers exercise this option is another story, and it’s been my experience that employers rarely interfere.

 

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Friday Q & A

There were many questions about Unum this week, so I’m addressing them all at once. It would be great if this company could pull itself together, but alas, I don’t think it’s going to happen!

What can you tell me about Unum’s employee harassment? Working here is unbearable.

Where do I begin? Unum does not like it when employees think outside the box. Claims personnel MUST subscribe and support Unum’s denial agenda or they are terminated for poor performance. If you are a female nearing 50 years of age, Unum also begins to discredit your work for future dismissal. Apparently, Unum hires young 20-25 year olds with “A Type” personalities and literally gets rid of older female employees. Older men are also terminated but it is usually due to increased medical issues.

In conjunction with Unum’s Human Resources, managers begin to “pad” files with poor performance notations whether true or not. Peers are solicited to also document what a bad employee you really are. You may or may not be placed on probation. Your manager may also move your workstation away from the rest of the unit. Claim managers assign blocks of claims they know you can’t keep up with or manage. Basically, employees are “set up” and then fired.

Reports to me have included employees being fired for “not taking care of flups, or closing them”, and/or exceeding allowed cell phone minutes on company phones. Whatever the excuse that can be used, Unum will walk employees out the door, throw their belonging on the curb, and deny unemployment, severance, and other benefits.

In the end, there is no job security at Unum. Claims handlers are literally no more than glorified administrative assistants, are “used up” by the company and are then tossed under the train. Unum employees should be reminded that there are other employers that will treat you decent. There is life after Unum.

Unum keeps sending me letters that they didn’t get my update paperwork. What else can I do?

Unum is indeed in an administrative mess right now. Not only are the claims handlers uninformed and ill-trained, but the company is using outdated technology and can’t seem to keep up with its own claims business. In other words, it probably has a backlog – a panic situation for most insurers.

Insureds continue to report to me that claims reps are rude and condescending, lacking any type of understanding or compassion. But, the worst part of Unum’s current negligence is evident in Unum’s “muddled” and disorganized administrative process. Claims handlers do not seem to be “present in the job” so to speak.

The best thing that could happen to Unum is to be taken over by a more reputable insurer, if one can be found.  The company downsized to the point that it is barely managing its business. This puts insureds/claimants at a disadvantage in trying to manage through the claims process. In my opinion, Unum is definitely in administrative turmoil

Why doesn’t Unum answer my inquiries? The company is non-responsive it seems.

Yes, Unum’s claims handlers have enough to do without sending verification of documents received, or answering concerns. There are literally bare bones customer services although Unum never was a company who communicated “good news”.

For now, I wouldn’t expect prompt responses from Unum’s staff. Sometimes, your answer is the continued payment of benefits. I just don’t think Unum reps have a clue as to what they are doing.

 

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