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Archive for the ‘Q&A’ Category

I received a long work history questionnaire from Unum, Why do they need that?

Although Unum changed the name of the form slightly, the form is commonly called a TE&E, or Training, Education and Experience form. It is generally sent out to claimants prior to the beginning of an “own occupation” investigation at the change in definition of ERISA Plans. Generally, receipt of the form can be a clue that the TSA (Transferable Skills Analysis) is about to begin.

Group insurers are looking for “transferable skills” so that they can locate gainful alternative occupations claimants can do given their current medical restrictions and limitations. However, any occupation investigations are inherently flawed and are subject to the GIGO principle, namely “Garbage-In, Garbage-Out”. Many insurers omit updating to current R&Ls and as a result the TSA provides “garbage-out”.

The TE&E questionnaire asks about your work history and, of course, claimants tend to fill up every little space on the form with information. I recommend instead sending a Resume, or a “less is more” completed form. In any event, the TE&E is used to perform the TSA looking for comparative skills and training that can be used to work in alternative occupations.

I’ve been asked to do a field interview. Is my claim in jeopardy?

Requests for field interviews indicate there is a “red flag” somewhere in the claim. Usually, insurers request field interviews after surveillance in an effort to “trap” insureds with “inconsistency of report.” Or, there are financial issues that are unclear, or perhaps suspicions of unreported earnings, or other inconsistencies that suddenly appear in the file.

The point is, however, that while most insureds just want to resolve the “field interview issue” there is always an underlining, and more serious “red flag” that caused the insurer to request this particular “risk management” activity in the first place. Field interview requests do not just pop up out of thin air, but are requested because of “red flags” identified in the file.

What are some of the most dangerous mistakes insureds can make when managing their own claims?

Glad you asked – here they are.

Not immediately obtaining a copy of your Plan or policy at the time of enrollment or purchase. One of the most frequent Nee statements is: “You can’t defend what you don’t know.”

Talking with insurance reps on the phone. While I’ve probably written as many as 30 articles on the danger of speaking to insurance reps on the phone, nearly every new caller describes verbal conversations that put their claims in jeopardy. Your contracts DO NOT require you to speak verbally with insurance reps and you should NOT do it, particularly if you are taking pain or depression medication.

Presuming your insurer acts in your best interests. Actually, the opposite is true. All insurers have a “conflict of interest” as both payers and reviewers of claims. All insurance companies act in their own best interests, not yours.

Avoiding conversations with physicians to discuss how doc-to-doc phone calls should be handled. If YOU aren’t speaking on the phone to your insurance company why would you want your DOCTOR to do it? Physicians are NOT required to participate in doc-to-doc calls anymore than you are. And, your doctors will appreciate  hearing from you that you do not give him/her permission to do it. Always speak with your doctor about what you will allow, and what you refuse to give permission to.

Not showing up for a requested IME. All Plans and policies require insureds to “show up” for Independent Medical Evaluations. The quickest way to denial is not showing up.


consultingDCS is a national consulting organization that provides expert claims management services to those with private insurance. I offer free initial consultation.

If you need help with any of the issues written about today, please feel free to give me a call to discuss how you can come on board as a DCS, Inc. client. I’m more than happy to speak with you concerning your particular claim.

If you need assistance with filling out your update forms or questionnaires, please feel free to give me a call. I offer reasonable per hour fees in addition to full management assistance.

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 BlogHome 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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Friday Q & A

How is appropriate care determined?

Nearly all group STD/LTD Plans today have some type of statement regarding the requirement of claimants to remain in “regular and appropriate care.” This means that claimants are required to consult with physicians who are qualified to treat the impairment for the claimed disability.

Most claimants understand it isn’t appropriate for a family physician to validate disability for a depression claim, or consult with an internist to support FMS and CFS. Insurance companies want to make sure claimants are treated by medical providers with specialties and credentials suitable to the impairments they are paying for.

“Appropriate care is determined, or should be anyway, by the treating physicians themselves who can document, “Given this patient’s medical history and consultation, I have determined that quarterly visits are appropriate care”, or something to that effect.

If undocumented by treating physicians, “appropriate care” can become an issue. Insurance companies should never be allowed to determine what is, and what is not appropriate care. Since third-party reviewers do not actually examine or treat claimants, they could actually be put in harm’s way because insurance companies dictate appropriate care under threat of claim termination. A statement from your physician that the treatment you are receiving is “appropriate care” should be documented.

Where are Unum’s checks mailed from?

Unless Unum changed its process, all communications and checks are mailed from Columbia, SC.

How is the definition of pre-disability earnings determined?

Pre-disability earnings definitions are in the Plans under the title: “Definition of Monthly Earnings” and are different in each employer’s Plan. Some define “pre-disability earnings” as “previous year’s W-2″, or salary just prior to date of disability” etc. Other provisions add bonus and commissions, or exclude it, same with contributions on your behalf to 401(k) Plans.

Considering Unum and Sun Life’s focus on recapturing every nickel and dime of overpayment, I have suspected that if claimants actually go back and calculate the pre-disability earnings, it might turn out these companies actually owe you. The same is true if your Plan has a COLA, or Income Revenue Protection (TIA-CREF) contributions not made. In any event, all claimants with ERISA Plans should compute pre-disability earnings to verify payment of benefit is accurate.

Who would you consider the best and worst disability insurers?

I love it when readers ask me this question. The top worst private disability insurers in 2018 are:

  1. Unum Group is generally considered the worst.
  2. CIGNA
  3. Aetna
  4. MetLife
  5. Mass Mutual
  6. The Hartford
  7. Reliance Standard
  8. Aflac
  9. Guardian/Berkshire
  10. Mutual of Omaha
  11. Liberty Mutual and Lincoln Financial
  12. Trustmark
  13. Ohio National

The best IDI insurers are:

  1. Northwestern Mutual
  2. Principal

There are NO best group insurers in the US or the UK.

 

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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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