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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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Friday Q & A

Can I go to Disney while on disability? Can I play golf while on SSDI? Can I go to Canada to see my family while disabled?

I’ve been doing quite a bit of talking on this subject lately. Apparently, there is quite a bit of interest in just how far insureds can stretch their medical restrictions and limitations and still get paid. Disability reporting is serious business and whatever medical restrictions and limitations reported by doctors to insurers should be adhered to, if only for your health’s sake. Reporting excessive medical restrictions for secondary gain could be interpreted as insurance fraud, evidenced by the fact that although you reported R&Ls, you’re clearly not abiding by them.

What you can do for activities depends on what your R&Ls are. If you’re telling the insurance company you are severely fatigued and cannot work, then of course you shouldn’t be playing 9 or even 18 holes of golf. If you reported chronic pain and limitations in standing, walking and sitting, then I don’t see how you could possibly walk around Disneyworld, or go on any rides. It’s possible, but prolonged standing and walking is equivalent to around 10 METS and demonstrates “sedentary to light” functional capacity, whether you can actually go back to work full-time or not.

There is a fine line between demonstrating “work capacity” and being able to return to work full-time. I get that. Still, in my opinion, anyone who can play golf, a very physical and mentally focused game, could probably work, at a minimum, a sedentary job. Whatever you are reporting to your insurance company as a restriction, is what you can’t do, and shouldn’t do.

Why are Unum claims handlers giving me inaccurate information? The reps don’t seem to know what they are talking about?

I’ve noticed the same thing, but unfortunately it’s not just Unum – all insurers now seem to be hiring the walking dead. There are quite a few claims handlers who seem to share contractual information that is inaccurate at best. What bothers me the most, however, are insureds who do not have copies, nor have they read their policies, and would never know the difference between accurate information and misrepresentation. Insurance companies can only get away with deception when insureds/claimants are not knowledgeable about the process.

It is very important for insureds to “correct the record” when reps communicate inaccurate information – something DCS helps our clients do on a regular basis.

What about these Unum Questionnaires I get all the time? Are they trying to trick me?

Recently, I was asked by a client to help him with a questionnaire received from Mutual of Omaha. As I read through the document I was taken aback by the amount of private activity information asked. Although insurers do have the right to investigate claims, insureds should know that there a line that can be drawn between “investigating claims” and excessive prying for the purpose of getting insureds to admit to work capacity without realizing it.

Insurance questionnaires are often wolves in sheep’s clothing. And, insurers are well aware that the first instinct of insureds is to fill up every empty space on the form with information – a real claims faux pas. “Less is more” when it comes to filling out Questionnaires and insureds should NEVER volunteer information not asked. All insurance inquiry forms are designed to encourage insureds to voluntary provide information about activities that can be compared to work capacity. If, by filling out the forms, you give yourself work capacity, even better for insurers – less work for them.

 

 

 

 

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Friday Q & A

Why are mental health psychotherapy notes so sought after?

There are basically two reasons why therapy patient notes are frequently requested, 1) patient notes in general are easy to misrepresent and interpret, and 2) patient notes can describe aspects of mental health used as indications of work capacity.

Most therapists today won’t provide therapy notes because they are aware of how the records are abused by insurance companies. And yet, this question is a very good one.

ALL patient notes, whether psychotherapy or physician notes are opportunities to “stack the deck” against insureds. Benign comment such as, “Patient feels well today”, and “Patient spent time with family over the weekend” are opportunities for insurers to allege work capacity. This is why a CIGNA rep told me last week the company pays no attention to “completed forms”, but must have patient notes as proof of claim. Then why keep chasing the forms?

Insurers are well aware of the fact that patient notes are not written by therapists to support disability, and therefore mental health restrictions and limitations are not often found directly in patient notes. Prudential, for example, absolutely insists on obtaining patient notes and then denies claims citing what’s NOT in them.

Mental and nervous insureds and claimants should always discuss with their treating professionals what to do when insurers request patient notes. Plans and policies do not specifically require the submission of psychotherapy notes as proof of claim

Can Unum exceed the 90-day ERISA timeline for review of claims?

Of course it can – any insurer can, not legally mind you, but then again, who’s watching? It’s possible the new ERISA amendments might buy you some interest from the EBSA (agency of the US Department of Labor) in the form of a complaint, but don’t count on it. Laws that do not provide a means of enforcing or backing them up aren’t helpful to claimants.

Violating ERISA deadlines as a “pattern of practice” indicated in the Administrative Record might be proof of “arbitrary and capricious” behavior, but generally violating ERISA timelines, although documented, are mostly ignored.

I can’t understand what my Unum correspondences are all about? Any clues?

Unum’s reps are getting very lax about putting together letters that make sense. Any insurance letter generally cites more than several policy provisions over and over again, presumably to heighten letters to scary levels of insureds’ tension and stress.

Today, the job of insureds/claimants is to cipher through all of the policy regurgitation and pick out what the claims handler is really asking for. To complicate matters Unum often sends out letters for no reason – such as the letter informing you that you and the company have the right to request an IME – a left over requirement of the Multi-State Settlement Agreement. That’s it.

Insureds need to become very skilled readers in that they are required to sift through all of Unum’s rhetoric and identify the one sentence that tells them what Unum wants.

Unum sends me copies of all of my client’s letters for deciphering which can be a real challenge for most insureds.

 

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Friday Q & A

Where does Unum mail checks from?

Unum has a data center in Columbia, SC and all mail comes from there. Your claims handlers initiate all correspondence from their location, but it is actually sent out from Columbia, SC, as are benefit checks.

While on this topic, remember we just had a Memorial Day holiday and we’re heading toward 4th of July and then Labor Day. Unum is the only insurer who seems to have a problem with getting checks out on time around the holidays.

Since Unum’s inefficiency increased in the last year or so, checks may be late around the holidays. If you can’t stand the stress of waiting, just call or fax your claims handler to inquire when you can expect to receive your benefit. You’ll mostly reach Customer Service because Unum’s claims handlers take PTO time during the summer and manage to mess up the already  messed up claims process.

Is the release of my psychotherapy notes protected by ERISA?

No, it isn’t. However, some states do have statues that protect mental health records such as Florida and to some extent California. Massachusetts allows support of disability claims in summary format (filling out forms).

In today’s terms, ERISA protections are limited to timelines and disclosure requirements. The courts have eroded the original intent of ERISA to protect insurance companies more so than claimants.

What is a nervous disorder?

A mental disorder (including a nervous disorder) defined for disability purposes is any behavioral impairment listed in the DSM-5 for mental disorders. Any impairment not listed in the DSM-5 would NOT be a mental disorder for disability purposes.

Unfortunately, the DSM-5 has a new section for “somatic” disorders and FMS and CFS are included in that category. This is why insurers are classifying FMS as limited to the 24 month benefit period for mental disorders. Basically, any patient who obsesses over their medical conditions has a mental disorder – at least according to the DSM-5.

Is my Administrative Record from Unum complete?

Probably not. Clearly, Navilink,, Unum’s diary system is not going to contain a complete record of all activities taken on the claim. If Unum is still conducting roundtables and team meetings to discuss claims, you can be sure it’s not recorded in Navilink. It also looks to  me that records from Unum’s website portal aren’t included in the Administrative Record either.

It used to be that Unum claims handlers were told, “If it’s not documented in the file, it didn’t happen.” Today, most of what DOES happen to claims is not in Navilink. The Multi-State Settlement taught Unum that over documenting claims leads to law suits and fines.

Therefore, in my opinion, no Unum Administrative Record is ever complete. IME and group underwriting files are also left out.

 

 

 

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Friday Q & A

Does Liberty Mutual hire police departments to investigate claims?

I think it is highly unlikely that any police department would use its officers to conduct insurance investigation. It is entirely possible, however, that some individual police may moonlight as  insurance investigators, but some towns, counties etc. have rules against taking on part-time jobs.

Assuming that most policemen/women tend to be honest, insurance companies would have a hard time influencing or controlling their reports. Police departments are also understaffed and would not allocate resources to insurance investigation. If anyone has any different information about police involvement, please let me know.

That said, IF the state Attorney General has reason to believe there is insurance fraud involved, and IF the issue of investigation rises to the state level, police resources could be used as deemed appropriate. But,  police departments are not utilized routinely, as far as I know, for insurance investigation.

Lucens wants an Authorization from me and I don’t want to give it. What will happen to me?

I receive many inquires about the infamous Lucens, Unum’s paper chaser, and the answer is really quite simple – Just say “No.”

No Unum Plan or policy requires claimants/insureds to give up private SSDI information as proof of claim. And, I’m going to say this again, “The only duties or enforceable accountabilities for claimants/insureds are those specifically written in the Plan or policy contract.” Claimants, for example, have a Plan duty to provide requested information within 45 days of requesting it at their own expense, but the requirement to give up SSDI files is not there.

The problem is that claimants are so scared. Yesterday, a caller said to me, “I don’t want to make Unum mad at me.” As I have said so many times in my articles those who are too scared to defend their Plans, policies and claims usually wind up with denied benefits.

In any event, there is no contractual Plan or policy provision requiring you to sign SSDI Authorizations. Just say “No.”

Can an insurance company take more than 90 days to make decisions on claims?

According to ERISA, group insurers have an initial 45 days to make decisions but can toll for another 45 days, a total of 90 days. However, who is enforcing the law? I know claimants call me all the time to ask about ERISA’s timelines but they are nothing to get excited about.

While the U.S. Department of Labor has jurisdiction over ERISA, breach of ERISA timelines is not regarded as a serious violation. Usually, exceeding timelines is sometimes cited by a judge during the administrative review of claims and can contribute to the “arbitrary and capricious” standard used by the courts.

Although, citing the breach of ERISA timelines may be a useful tactic during the management of claims, insurers put these allegations on a “pay no mind list” because they know the violations are virtually unenforceable at the time.

 

 

 

 

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What is Unum’s “aspire program?”

I’ve already written a post about Unum’s “Aspire” program that sends carefully selected, top-claims deniers to Disneyland for yet more indoctrination and brainwashing. Management gets a great deal of control mileage by using the “Aspire Program” to push claims handlers to be “experts” at meeting the company’s termination agenda.

I’ve never understood why adult employees who, in my opinion, are already working for Ali Baba and the Forty Thieves, would want to go to Disneyland for a week to be indoctrinated. I’m hearing a lot about this lately so it must be time for Unum management to make their picks.

Resignations

The topic of resigning from work before, during, and after disability is by far the most frequent question I receive. There is an excellent post on this blog called, “Resignations – A Disability Claim No-No.” I strongly suggest that you search this topic and read the post.

In short, no one should “resign” from a job when leaving work for disability reasons. NO ONE. Basically, employees should notify HR that “my doctor is recommending a period of total disability as of a specific date.” There is a big difference between notification of impairment and “I quit.” Please read the above mentioned post.

Why would Unum want to look at my SSDI file?

Whenever Unum asks for additional information it usually means it is looking for something and SSDI files are no different in motive. To begin, the Multi-State Settlement Agreement stipulates that Unum should “consider” SSDI information before making their own liability determination. So, Unum requests SSDI files to cover their behind. Not that it actually “considers” the information, but at least if they have it, Unum can say they did.

Today, Unum is asking for SSDI files for the intended purpose of chasing down nickels and dimes of offset errors, mostly from those who have been on claim for some time. The longer you’ve had SSDI approved, the more likely there are to be errors in calculation which presumably Lucens is helping them with.  Unum’s calculations are bizarre and m most people can’t even figure out where the overpayment came from.

In addition, Unum is looking to get a copy of SSA Form 831 in order to determine if mental health listings were used to award benefits. If so, Unum alleges they “agree” with SSA and will limit benefits to 24 months.

Unum’s letters that encourage signing of the SSA Authorization claiming, “we want to make sure we give your claim every consideration” is fabricated untruth. Once Unum obtains SSDI files, it still denies claim benefits saying, “we have evidence that SSA didn’t have at time benefits were awarded and therefore we disagree with the decision SSA made.” What a racket! Why give up your SSDI files when your Plans and policies do not require you to do so?

How do I show 20% of disability earnings?

This question really illustrates a huge misconception. In order to be eligible for continued benefits while working, insureds are required to have at least a 20% earnings loss based on pre-disability earnings, sometimes “indexed” pre-disability earnings. Sometimes it’s helpful to look at this issue from the opposite direction.

Part-time workers cannot exceed 80% of pre-disability earnings and still keep their benefits. Therefore, claimants who are working part-time really need to keep track of their earnings and make sure they do not exceed 80% of pre-disability earnings. Therefore, claimants will have also met the 20% earnings loss requirement by not earning in excess of 80% of pre-disability earnings.

How long will I receive my benefits?

Technically, you are entitled to receive benefits as long as you meet the definition of disability as written in your policy or Plan. However, we all know that insurance companies determine who does, and who does not meet, that definition and benefits can be denied at any time.

Because of the certain “conflict of interest” in that insurers are both payor and reviewers of claims, benefits from private disability are uncertain at best.

ERISA Plans pay until age 65 (or normal retirement age), but IDI policies either pay to age 65 or provide for Lifetime benefits.

 

 

 

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