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Archive for the ‘Q&A’ Category

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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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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Friday Q & A

Unum is forcing me to apply for SSDI. Can they do that?

Unum has a great deal of say-so when it comes to forcing claimants to apply for SSDI, but even when you don’t apply for benefits Unum can still offset benefits. Most Plan documents contain provisions that write, “when we determine you are eligible for SSDI”, which gives Unum a great deal of leverage in forcing claimants to apply for benefits.

Actually, ERISA Plans do not have provisions that say claimants “must” apply, but there are provisions that say Unum has the right to “Offset” benefits you are ELIGIBLE TO RECEIVE, OR ARE RECEIVING. Ouch!

This means that any additional income claimants are “eligible to receive”, such as pensions can be offset from benefits even if you’re not currently receiving them. It’s a good thing Unum’s Plans also contain provisions that prohibit Unum from offsetting SSDI as long as claimants continue the application process through at least two appeals – reconsideration and Administrative Law Judge.

Lately, Unum is clearly harassing and threatening claimants about SSDI to the point of taking estimates from benefits out-of-contract. It’s unclear whether this is due to Lucens’ involvement in the process, or perhaps management’s attempt to garner every financial reserve dollar.

There isn’t anything in Unum’s Plan that says Unum can take an estimate from benefits if SSDI doesn’t make a decision within a certain time frame. Although Unum is now threatening to do that, it can’t really follow through because it’s an out-of-contract unfair move.

As an aside, let me caution claimants that requesting SSDI estimates be taken from benefits is not a good idea since Unum doesn’t pay them back if claims are denied or SSDI isn’t awarded.

How do I go back on claim after I tried to return to work but can’t do it.

This is actually a very good question. Failing to show up to work, again, ins’t the right thing to do. First, you consult with your treating physician and explain why you are unable to remain at your job. The doctor then documents into the record that you are totally disabled, incapable of continued work as of a certain date, and after you have informed your supervisor of the physician’s recommendation you stop working.

Next, you should send Unum your patient notes and records pointing out that you are unable to remain at work and wish your claim to be reinstated under the Recurrent provisions of your policy. This only pertains if you returned to work full-time with your same employer. If you returned to work part-time making sure you were working the “minimum number of hours” required, you would need to file a new STD claim.

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Friday Q & A

Does SSA conduct surveillance?

Yes they do if they have reason to suspect fraud. The Social Security Administration cannot afford surveillance on everyone, but if it has reason to expect fraud, or someone contacted them to report a fraud, it will conduct surveillance.

As I used to tell my kids years ago, “If you don’t do anything wrong, you won’t have anything to worry about.” The unfortunate thing is that angry neighbors and disgruntled spouses are the primary informers of suspected but unsupported fraud. SSA has no other option but to investigate even though most charges are unfounded.

What are the recurrent provisions and why are they important to me?

Most policies and Plans have what is referred to as the “Recurrent Provision.” Put simply, it states that if the insured or claimant returns to work full-time and is unable to remain at work for 6 months, he/she may come back on claim and not have to meet another Elimination Period.

Of course this is easier said than done. Insureds who cannot continue working may find that insurers will put them through another intensive investigation before re-opening its financial reserve again. One of the worst things insureds can do is to keep going back to work, then out again, back to work, out again and so on. Eventually insurers will get tired of that and  will deny the claim alleging claimants can work full-time.

Notice, you have to return to work full-time (with same employer in some cases) in order to be eligible for the Recurrent Provision.

What is the difference between “passive income” and “earnings?”

Wow! This is a topic deserving of a much longer discussion than on the Q & A. Although the question is quite complex, basically “passive” income is income you do not have to perform work to receive.

Passive income is reported on Schedule E of your federal tax return and includes such items as copyrights, royalties, rental income, etc.  Capital Gains reported on Schedule D, and Dividend and Interest Income on Schedule B is also passive income and is not subject to self-employment tax. This is income received for which the taxpayer does NOT “materially or actively participate” to receive.

On the other hand, income reported on Schedule C “Income or Loss from a Business Profession” is considered earnings and IS subject to self-employment tax. Schedule C asks the question, “Do you materially participate”; and, this is where disability insurers get you.

If you respond “No”, then claiming losses are limited; responding “Yes” tips insurers that you are engaging in a business and the income is considered earnings.

Professionals with multiple investments with K-1s should pay particular interest to these issues since insurers will consider K-1 income as earnings and may decide to pay you “residually” even though you are totally disabled and not working.

Why isn’t Prudential a good company?

Prudential is an unfair insurer because it is run by ex-Unum management such as Cathy Liston, who used to be a VP at Unum. Prudential doesn’t fall too far from the Unum tree.

 

 

 

 

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Is Unum Hospital Indemnity insurance a good deal?

Unum bolstered its group offerings with hospital indemnity and catastrophic insurance as riders to its group Plans. Employers offer the insurance, but often require employees to pay the additional premium. If Unum engages in bad faith and egregious claims practices for disability claims, doesn’t it make sense it would do the same for any other line of insurance it offers? As an example,  Unum’s Long-Term Care insurance was a disaster and that line of business was eventually dropped.

Insureds should consider the cost of any additional insurance Unum offers very carefully to determine whether the premium is worth the risk of not getting paid. What the company does to “not pay” claims for one line of business it can clearly do for all others.

What happens when I return to work after a period of disability?

If you return to work full-time with your same employer, but cannot remain on the job more than 6 months, you may go back on claim without having to meet another Elimination Period. Keep in mind, insurers will put you through an extensive investigation prior to reinstating your claim. This is why it is so important to make sure that once you return to work you are physically and mentally able to remain there.

If you return to work part-time with any employer under most Group Plans you qualify for the Work Incentive Benefit Program (WIB) for 12 months. You would actually qualify for “residual” benefits under the old group Plan while at the same time gaining eligibility under a new STD/LTD Plan for a new employer.

You would need to notify SSA of your return to work either full or part-time. Under SSA’s work programs you may be able to keep your SSDI for a limited period of time depending on the number of hours worked up to certain earning limits. SSA’s Red Book for return to work is extremely helpful in describing return to work benefits under SSDI.

Most Group Plans offer an incentive for insureds to return  to work such as the WIB program that allows claimants to work and keep both earnings and monthly benefit for a period of 12 months. Although claimants must still have a 20% earnings loss, the program is intended to be an incentive to encourage people to return to work.

Will Unum deny my claim after I send them the overpayment for SSDI?

Yes. Unum does have a “pattern of practice” of doing that, but then again all other group insurers often do the same thing. In my opinion, this is one of the great legal estoppel associated with disability insurance.

Group insurers force claimants to apply for SSDI which has a “total disability from any occupation” definition. Then, once SSDI is approved, Unum (and other insurers) allege claimants can work and deny claims – the greatest estoppel that is never enforced!

In simple terms, an “estoppel” is something that can be used to benefit you, and then also used against you. Disability insurers force claimants to apply for SSDI to reduce their total liability for claims. First, insurers sell SSDI as a great benefit to insureds, and then once the overpayment is collected, SSDI is ignored and claims are denied.

Think about this. Insurers sell group and other disability Plans based on a 60% pay out rate on which premium is based. Then, the government allows companies like Unum to reduce total future and financial reserve values by SSDI received by claimants. Employers actually pay premium on one thing, and employees receive something else.

As I said, this contradiction between SSDI’s value to claimants and the fact that once overpayments are recovered insurers can deny claims is a great estoppel that is not legally challenged.

It is extremely unfair to claimants to allege they are totally disabled for one purpose and not disabled for another.

How do I win a claim for Guardian Berkshire?

Well, that’s the million dollar question these days isn’t it? Guardian’s paranoia when it comes to investigation is not producing a good public image of the company’s products. At one time Guardian was a fair reviewer, but in the last few years a distinct change occurred giving the public the impression that Guardian is more concerned with a person’s credibility than whether they meet the definition of disability or not. If there’s dirt and smut out there about insureds, Guardian is sure to find it.

In addition, I’ve found that Guardian has strange ideas about interpreting its policy provisions. Payment is not always consistent with “residual” definitions written into  actual policies. Insureds would do well to be very familiar with their contractual policy provisions and be ready to defend them.

Winning a claim with Guardian/Berkshire is unreasonable and untimely, a fact that, in my opinion, should be considered very carefully by potential buyers of Guardian’s products. The company’s investigation of claims is way over the top and exceeds what would normally be considered necessary for disability claims.

 

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