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Archive for the ‘Q&A’ Category

Friday Q & A

Where are Unum checks mailed from?

Unum’s checks are mailed from Columbia, SC. All communications into and outgoing from the company also come from Unum’s data center located in Columbia, SC. I understand Unum is in the midst of a chaotic reorganization right now, but so far it looks as though the checks will still come from SC.

What is a Life Waiver of Premium claim?

Most disability policies (and life policies) have a Waiver of Life Premium provision that excludes the payment of premium for life insurance while on disability. Policies also exclude the payment of disability premium while on claim.

Life Waiver of Premium provisions most often require insureds to be totally disabled from performing ANY occupation and therefore it is possible to get paid for an own occupation disability claim, but the Life Waiver is denied.

For example, during the first 24 months of a paid claim, the insurer pays for own occupation disability but doesn’t accept the insured is totally disabled from ANY occupation. Therefore, it’s likely that Life Waiver of Premium won’t be approved until the transferable skills analysis is done at the any occupation to determine if the insured is totally disabled from ANY occupation in the national economy.

Please do not get confused with “disability premium waiver” and “life waiver of premium.” Insureds and claimants do not have to pay disability premiums once their disability claims are approved. By the way, Life Waiver of Premium provisions can exclude premium payments for disability even if the life policy is underwritten by another company. It’s always a good idea to check your life policies to see if they have a Life Waiver of Premium for total disability.

Are insurance field interviews HIPAA protected?

Absolutely not. In fact, all records held by disability insurers are not protected either. Disability insurers are specifically excluded in the law as HIPAA “covered entities” and therefore, files at Unum or CIGNA, for example, are not HIPAA protected.

Again, even though Unum’s Authorizations are HIPAA approved, the auths themselves say that once the information is released it loses its HIPAA protection. Although HIPAA laws do not include disability claim protection, the medical records forwarded to insurers are protected. But again, once you sign an authorization releasing the records the first time, they lose HIPAA protection.

HIPAA actually doesn’t provide all that much protection for privacy of medical reporting. It just sets guidelines for the electronic transmission of medical records or medical information. This brings up the argument as to whether doc-to-doc phone conversations are HIPAA protected. In my opinion, they are, and that’s why many treating physicians are now refusing to speak with insurance docs.

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Friday Q & A

How can I challenge an insurance neuropsyche test?

Anytime an insurance company asks you to present for a neuropsyche test it is very important that you also either retain or inform your own neuropsychologist that you would like to obtain the actual test booklets and raw data (the tests themselves), for independent review and comment.

Although the  insurance industry tends to place neuropsychological tests in an “objective category”, the results clearly are NOT objective. Each insurance evaluator chooses a “battery of tests”, administers them, and compares responses to normative statistics and values in the national economy. Finally, the evaluators render an opinion as to what the results mean. Clearly, neuropsyche tests are NOT objective measures of disability, cognition, somatization, or malingering and should not be allowed to stand alone in anyone’s disability file.

Copies of test booklets, and raw data should be provided to your own independent evaluator for comment and rebuttal. If this is not done, the results will be presumed to be accurate and will stand in the record. All IMEs, whether neuropsyche or not, should be provided to treating physicians for rebuttal. Absence of comment from your physicians is presumed to be in agreement with the IME reports.

What is the percentage of income that IDI policies pay?

Individual Disability Income Replacement policies do NOT pay based on a percentage of pre-disability income. IDI policies always pay the “scheduled amount” indicated on the cover sheet of the policy. Therefore, IDI insureds are buying a fixed benefit (scheduled amount), with the opportunity of Future Option Increases at various intervals along the way.

People sometimes confuse ERISA Employer Group benefits that pay most typically 60% of pre-disability earnings with IDI policies that pay a fixed scheduled amount. IDI insureds may choose a level of coverage as long as the underwriting of the benefit doesn’t exceed actuarial guidelines for overinsurance.

In contrast, ERISA Plans pay a certain percentage of pre-disability earnings and employees may not choose their level of benefits except if the Plan is a welfare Plan and includes several levels of payment such as 50%, 60% or higher. Some employers may offer supplemental “buy-up” Plans as well, but benefits are always a percentage of prior income.

I can’t get ahold of anyone at Unum. Is Unum still a company?

I presume Unum is still a going-concern, however, I have been hearing from others how difficult it is to find someone to speak to. Settlement specialists are non-existent, and even attorneys are finding it difficult to get to the right people.

Unum has been chaotic for quite some time now. The company continues to terminate groups of employees while outsourcing a good amount of the claims process to other companies, and countries. There is very little about Unum that is reputable these days and no one should be surprised when they can’t find someone to speak to. I’m guessing it’s much worse than that.

Who is G4S?

G4S is an investigative agency retained by insurers to conduct surveillance and field interviews. Additional information about the company can be found online, but in short, insurers hire the company to conduct investigations.

Although the name G4S sounds like “you’re in for it”, I’ve found the company to be your everyday run-of-the-mill insurance investigative resource.

 

 

 

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Friday Q & A

Why does Unum want SSA Form 831 so much? The company is hounding me to sign an Authorization to get my file. Do I need to do that?

There are quite a few really good posts on the Blog about Unum’s scam when it comes to obtaining SSDI Files. If you do a search from the Home Page I’m sure you may find more detailed information.

Although the company alleges it, “wants to give your claim every consideration”, the truth is Unum does not. In fact, Unum’s obsessive attempts to obtain SSA Form 831 are more related to denying mental and nervous claims limited to 24 months. Form 831 is a form that is kept in each recipient’s file at SSA and includes the listing codes benefits were awarded for as well as the name of the DDS (Disability Determination Specialist).

In the past, former employees describe Unum’s abuse of form SSA 831 by using the information to try to contact the DDS. Now you know why Unum’s SSA Authorization is valid for two years.

I’ve been asked by Unum to have a neuropsychological evaluation. Why?

Unum seems to have a focus project going on targeting mental health and cognitive impairment claims. I’ve heard from several people who tell me Unum’s on a neuropsyche test rampage. Although neuropsyche tests are considered “objective”, the test, administered by doctors paid by insurance defense, is actually as opinionated and biased as you can get.

The evaluator chooses a “battery of tests” not necessarily to evaluate impairment, but to evaluate the insured’s “intent, motive and secondary gain” issues more than anything else. This is particularly true for FMS claims where IME evaluators deliberately do not choose tests that diagnose the disease at all.

In any event, the IME evaluator compares the scores from the raw data (test) and compares the tests to population normative data. Then he/she writes an opinion report based on the results. How objective and non-biased is that?

In my opinion, neuropsyche tests are primarily insurance defense tools to provide employers and insurers with documentation to not hire employees or deny disability claims. It’s a multi-million dollar “gotcha” game paid for by the insurance industry.

Prudential neuropsyche tests – are they a put on?

In continuing with the above discussion, I haven’t had a chance to talk about Prudential all that much lately. Still, I consider the company #2 bad boy after Unum Group.

The company does not have its own mind; it has a Unum mind. Many ousted Unum employees wind up at Prudential. The company hires old “claim killer” Unum IME and peer reviewer doctors to review claims.

When it comes to neuropsyche tests Prudential retains IME facilities who “coach” its doctors on what tests to choose and how to write reports. Some of these organizations actually “grade” the IME reports written by its doctors. IME reports written by doctors who are coached as to what they should write remove all defenses of the insured to ever receive benefits. Prudential truly uses these facilities to “stack the deck” against claimants.

Prudential uses medical reviews written by non-specialized Registered Nurses to deny claims. The company insists on reviewing mental health records in order to pay claims even when therapists don’t want to provide them.

Next to Unum, Prudential is another company to stay clear of if you are an employer looking to spend employee benefit dollars wisely.  Prudential disability benefits wouldn’t be a benefit to employees, but a casualty soon or later.

Are disability insurance companies subject to HIPAA?

No, the aren’t. In fact, disability insurers are explicitly excluded as a defined entity in the law. However, the doctors who provide medical records to Unum ARE subject to Unum and need to abide by the law.

This is why doc-to-doc calls between insurance doctors and treating physicians should not take place. Using the phone is an electronic submission of health information. Treating physicians should make note of that.

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Friday Q & A On Wednesday

Does a Unum denial affect my SSDI?

I am not surprised at how often I’m asked this question. A disability claim denial does not affect SSDI approvals since the benefits are a federal entitlement that has nothing to do with private insurance.

SSDI approval is based on a 5-step procedure that determines whether an individual meets SSA “listings”, and has enough “quarters” accumulated to receive benefits.

Although I am aware that Unum in particular continues to attempt to obtain SSDI information it really has no right to, the bottom line is that Unum, a public corporation, has no authority when it comes to federal entitlements. Therefore, no private disability insurance denial has any effect on SSDI benefits.

How long do I have to submit ongoing “proof of claim” to Unum?

An easy answer to this question would be for me to say, “please read your policy or Plan” because deadlines ARE written into the documents. For Unum ERISA Plans, claimants are given either 30 or 45 days to provide requested information “at their own expense.”

The Plans also state in several places that “YOU” are accountable to provide the information. Unum’s objection to breaking the “chain of evidence”, so to speak, by insisting it obtain records directly from physicians is actually a request that is out of Plan or contract.

On occasion, Unum claims reps have strange ideas about enforcing short deadlines, but ERISA Plans allow 30-45 days as of the date the written request is received.

DI policies specifically state insureds have 90 days after the end of any month for which benefits are requested to submit proof of claim. Most insureds do not enforce these provisions because they want to get paid every month. However, Unum cannot deny a claim for “failure to provide” unless the request is over 90 days.

How does Unum calculate overpayments?

Although there are several previous posts on Lindanee’s Blog having to do with this question, the simple answer is that Unum’s program (which is the same one I helped to design when I was still there), calculates as follows:

What we [Unum] should have paid – What we did pay = overpayment – attorney fee = net overpayment.

Unum’s program actually breaks the calculations down into days, but in general, this is how all SSDI overpayments are calculated for nearly all overpayments.

How do I withdraw my Unum policy?

Simply write a letter to the claims handler after you receive your next benefit requesting that it be withdrawn. Although DCS, Inc. doesn’t recommend that claimants do this across the board, for some, it’s a good resolution.

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Friday Q & A

What’s so important about Unum’s LTD Manual?

Nothing. Absolutely nothing. Although there is sometimes a great deal of interest in obtaining “Unum’s Benefit Manual” there is nothing particularly hidden or important to the claims process contained in it. Consider. Would Unum really give away its secrets on a manual CD it gives out freely to those with denied claims? Not hardly.

Although attorneys scramble to obtain copies of Unum’s Benefit Manual, the information does not lead you through the claims process which IS hidden. For example, readers can’t take the Benefit Manual and use it to lead you through claims review procedures step-by-step. (What you do first, than second, than third….) In reality Unum’s claims manual describes basic information, gives definitions, some specific procedures, but does not lead anyone through the claims process which is what is most important to know.

Unum doesn’t inform outside parties as to what its internal claims process is and clearly its Benefit Manual doesn’t provide that information either. Any attorney really interested in the claims review process should depose Claims Managers and VPs. These are the culprits who really know what the process is. Claims handlers are merely pawns and only do (and say) what they are told.

Is Ohio National a “conflicts of interest” policy?

Well…..all private disability polices represent a “conflict of interest” since the insurance company is both reviewer and payor of claims. Disability insurers realize profit when they DO NOT pay claims, rather than PAY them. The profit risk is called the “law of large numbers” and basically says that the more policies sold, the less polices will be paid. Using that basic tenet, insurers raise the bar, of course, by artificially denying legitimate payable claims. Therein lies the true conflict of interest.

All disability policies have an inherent conflict of interest particularly ERISA employer-provided Plans wherein “discretionary authority” comes into play. “Discretionary authority” gives ERISA Plan insurers (who supposedly have fiduciary duties) to decide for themselves who gets paid and who doesn’t.

How exactly does an ERISA insurer act in the best interests of the claimant when they also have “discretionary authority? The truth is, no disability insurer is without conflict of interest and therefore ALL private disability insurers engage in unfair claims practices to some extent.

What is the average payout of a disability claim lump-sum settlement?

The process of disability claim settlement is much more complicated than just “what is the average payout.” There are several very good posts on Lindanee’s Blog that deals with private disability settlements. However, in brief, each claim has a different financial reserve which is (at least in theory), an amount of money put away to pay future claims.

First, future value (fv) is calculated and is then discounted (interest removed) to its net present value (pv). Then, a percentage of the pv is offered to insureds as a buy-out. Companies such as Unum won’t settle claims for greater than 80% of the financial reserve and therefore it becomes a guessing game to try to figure out how close the percentage of pv offered is to the 80% of financial reserve.

Other insurers aren’t as sophisticated as Unum with their math, but I’m sure they don’t offer more than the financial reserve either. To do otherwise would be punitive and the creation of liability or loss. There must be a financial reserve loss in order for settlements to be profitable.

Therefore, there is no “average” payout that can be quoted because each claim, benefit, and financial reserve is different.

What is an “advance pay and close”?

An Advance Pay and Close is when the disability insurer decides in and of itself that claimants and insureds can return to work as of a specific date. Then, an offer of advance payment of several months benefits is made in anticipation of the claimant being able to return to work.

Unum offers AP&Cs on a regular basis using only a quick medical review or Medical Advisor software as back-up to determine when claimants are recovered enough to return to work. Unum is well aware that claimants are often tempted to accept large chunks of money, particularly before holidays, and not knowing the consequences, they are more likely to accept an AP&C than not.

The truth is, Unum uses AP&Cs to close down financial reserves in the current month for future denials. This is very similar to Unum Life’s old “90 codes” that allowed claims handlers to shut down in the current period, claims they intended to deny within 90 days.

Unum attempts to make AP&Cs look legitimate by setting up arbitrary criteria such as 1) there must be a verified return to work date, 2) the claimant or insured must agree to the AP&C, and 3) AP&Cs can only be offered up to 6 months in the future.

However, resources have told me recently that Unum isn’t abiding by the criteria and is arbitrarily sending out future payments in anticipation of returns to work even when insureds are not expected to be recovered or able to return to work at all.

My objections to AP&Cs are that although the insurance company says it will put claimants back on claim if unable to work, they rarely do, or at best put claims through an intense investigation before they will begin to pay again. Second, no appeal rights are given to claimants in the AP&C letter. Unum and other insurers regard AP&Cs to be mini-settlements and not denials even though the financial reserves are shut down.

Insureds should not be enticed to accept future benefit payments in anticipation of returning to work unless a specific return to work date has been agreed to by the employer, and the claimant’s physician provided a work release.

Unum and other insurers depend on claimants’ need for cash to make this one work. Be careful with this one.

 

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Unum wants me to do a neuropsychological test. What can you tell me about this test beyond what you’ve already written on your blog?

Although neuropsyche tests are said to be “objective” in nature, in my opinion, that tag is not accurate. This test allows the insurance evaluator to choose a “battery of tests” that concentrates on issues of “somaticized”, or imaginary complaints, malingering, and other DSM-5 “cognitive” issues that in most cases have absolutely nothing to do with the insured’s actual diagnosis or evaluation.

In addition, the “raw data”, or actual tests are scored and are compared to common normative values existing in certain statistical categories; and then the evaluator writes a report giving his/her opinion as to what the standards means.

How can neuropsychological evaluations possibly be considered “objective evidence” when an evaluator who is not “independent” chooses the battery of tests and then write an opinionated report as to what the numbers mean?

If you ask 5 neuropsychologists to evaluate any particular report, you will most likely get 10 opinions. We’ve known for a long time that neuropsychology tests given to FMS patients are not accurate because the appropriate “battery of tests” aren’t administered.

A neuropsychological test is no more persuasive than any treating physician’s opinion based on clinical consultation alone. In fact, I would argue that at least treating physicians are using objective test results as diagnostic back-up for ongoing treatment.

In my opinion, Unum’s neuropsychological tests are nothing more than “battery test set-ups” culminating in opinions based on insurance conflict of interest.

I so desperately want to go back to work and I told my insurance company that. Now, they are harassing me. What do I do?

I advise insureds to be cautious about communicating an optimism about returning to work. There are several really good articles on Lindanee’s Blog that describe returning to work after a period of disability. When it comes to managing a disability claim insureds and claimants can only deal with the here and now.

Returning to work involves much more than just the ability to perform work tasks. It involves having to be somewhere every day and the ability to perform work in the context that any employer will expect the work to be done. It also involves regular driving to and from work, which for many people is problematic. Employers are not looking to hire individuals with work accommodations from the beginning.

The worst thing that can happen to insureds with disability claims is to attempt to return to work prematurely and not be able to stay there for any length of time.

In so far as a disability claim is concerned, expectations regarding returns to work shouldn’t be discussed beyond the medical restrictions and limitations given by physicians today. Truth is, insureds have no idea what the future holds for them and therefore communicating “I want to return to work” opens the door to harassment forevermore. Keep your optimism at bay and just deal with the “what is.”

Is Ohio National a good insurance company?

Ordinarily, I would say “No” because my experience with the company is that it does not consider outside treating physician medical information and refers all issues to  insurance attorneys who never want to resolve anything. Ohio National’s Attorneys refuse to provide copies of claim files upon denial and generally give insureds a very hard time.

Having said that, after posting a few negative posts about Ohio National, a representative from the company called me to ask for my feedback as to how to “fix” the claims process. She alleged that she had been assigned to try and improve Ohio National’s claims process. Whether she was able to do that or not I have no idea, but at least the company solicited input to change what wasn’t working – a novel idea for an insurance company

In my opinion, insureds with Ohio National disability claims should tread with caution while carrying a big stick!

 

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Additional Q & A

Did Unum actually give out the hungry vulture award?

Actually, Paul Revere and Provident were solely responsible for awarding the Hungry Vulture Award prior to the June 1999 merger with Unum Life Insurance.

Unum Life Insurance Company awarded monthly “Shareholder Value Awards” to claims handlers who denied the most claims. Both awards to claims handlers were given for the same reasons.

Both the “Hungry Vulture” and “Shareholder Value Awards” were discontinued once it was disclosed publicly why they were given out. The combined company, UnumProvident, had no such awards, and in fact management also did away with annual bonuses.

Due to public exposure, Unum Life Insurance also ceased its notorious “fishbowl lotteries”. Held once a month in the Unum Life Central Benefits Units, the “fishbowl lottery” required claims handlers to put slips of paper with their names in a large fishbowl and ring a bell every time a claim was denied.

Once an hour management pulled out a name and that person had a choice of various gifts that included grills, spa vacations, beach gear, dinner passes etc. The whole scam was to encourage claims handlers to deny more claims in order to win prizes. The Hungry Vulture and Shareholder Value incentives did exactly the same thing.

After 1999 claims handlers were only allowed $500 “Spot Awards” and of course, lavish lunches, candy, birthday cakes (need to watch Office Space, the movie nailed it!), trips to Disneyland, and meetings at manager’s houses.

I understand Unum Group still pays employees and physicians annual bonuses, another type of “fishbowl” incentive to deny more claims.

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