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Archive for the ‘Q&A’ Category

Can an IME physician refuse to give me a medical diagnosis and prognosis?

Those who ask this question do not understand the overall objective of insurance IMEs and IME physicians. The objective of a disability IME is to personally view the insured for the purpose of providing the insurance industry with written reports supporting non-payment business decisions.

IMEs are NOT intended to accurately diagnose, treat, or provide a prognosis for any medical or mental condition. Since IME physicians do not have a history of consultation or treatment with those they examine, it could actually be harmful for IME physicians to provide diagnoses or recommendations for treatment.

It’s important for insureds and claimants to know and accept the truth about insurance IMEs that rubber stamp management’s business decisions to deny more and more claims. If I were an insured I would not want any IME physician to give me medical advice – that’s not what they are paid to do.

Does Unum insurance have a cap?

Unum ERISA Plans pay a percentage of pre-disability earnings, 60% being the most common. However, the Plan will also stipulate a “maximum monthly benefit” such as $5,000-$10,000. While the maximum benefit is rarely reached by the employee rank and file, benefit maximums for executives are unattractive when earnings are greater than $100,000. This is why most highly paid executives also buy IDI polices to cover the additional earnings not paid from group Plans.

IDI policies pay the “scheduled amount” of monthly benefit located on the first page of IDI policies. Scheduled benefits can be increased by exercising future income increases and policies could contain COLA that will also increase benefit. Future increase riders and COLA are often limited in the number of FI allowed, or the number of years COLA is paid.

What is a mental disorder as defined by disability insurance?

For disability purposes, a mental disorder is defined as one located in the Diagnostic and Statistical Manual, DSM-5. If you want to know whether a diagnosis is classified as mental and nervous, look it up in the DSM-5 to see if it’s listed there, or ask your therapist. If it is listed, the diagnosis will be considered mental and nervous and subject to the mental and nervous provision.

I want to go to school while I’m on disability to prepare for another occupation. Is that OK?

Unfortunately, most insurers will interpret the ability to attend school and classes as having work capacity. In fact, it hasn’t been that long ago that Unum put the question about taking courses on its forms.

Each individual claim and situation, of course, will be different depending on what the impairment is, and what restrictions and limitations treating physicians are reporting. For example, if a claimant reports fatigue or chronic pain of some kind and yet is able to sit in a classroom three days a week….well, you can easily see how the insurer will interpret that as having at least part-time work capacity. Taking online classes gives you an Internet presence that can be hacked into at any time.

This is a good example of how insurance companies shoot themselves in the foot. Training for a new job will return insureds and claimants to work, it’s just that insurers do not want to wait that long. If insurers decide you have work capacity, the claim is usually denied and going to school could be one of the reasons.

Insurers wouldn’t be asking about it on forms if this were not the case.

Who was Steve Center?

Every now and then I get questions about “ghosts” from the Unum Life Insurance Company past. I believe Steve Center was President of Unum America and was one of then most strict, but colorful Unum executives. I knew him only briefly before he retired to help his wife run their Antique store in Scarborough, ME.

Who knows when Unum’s top executives actually knew about the merger with Chandler and his wise guys from Paul Revere and Provident. CEO Jim Orr III retired as did Steve Center, taking their golden parachutes with them.

Steve Center’s reputation for lining up women against the wall to check for runs in their panty hose will probably stay with him for a long time. Women employees always knew to keep extra panty hose (and heels) at their desks.

For the most part, Unum employees were afraid of Steve Center and made it a priority to stay clear of him for as long as possible.

 

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Friday Q & A

Will Unum accept a repayment plan for the SSDI overpayment?

Well, it might. Then again, it might not depending on whether you signed the Payment Option Form requesting to be paid a full benefit with a promise to repay. Unum’s POF form now sets up a voluntary lien against your assets if you don’t repay as promised.

Unum, and many other insurers actually “front” claimants the money they would normally receive as SSDI as long as claimants promise to pay it back. Of course, claimants want to receive their full benefit so they sign POF forms agreeing to pay back any overpayment due. However, when the time comes to actually repay Unum suddenly claimants want to know about repayment plans.

Unum has the right to reduce benefits to $0 to recapture the overpayment and/or seize assets from bank accounts (if the POF was signed allowing them to do so). The company prefers to recapture the total amount of the gross overpayment in the same taxable year therefore if that isn’t possible, Unum may decide to begin to attach assets.

DCS, Inc. takes the position that claimants should repay Unum what they promised to pay back. You can’t expect any insurance company to uphold their accountability under Plans and policies and then stiff them on the back-end. I understand that many claimants use the money to pay off bills and buy medications etc. but one way or another the overpayment should be repaid.

In the past I’ve suggested that claimants should have estimates removed from their benefits so that no overpayment would exist in the future. However, it’s become increasing clear that Unum will NOT refund SSDI estimates even when claimants are not approved for SSDI, or when claims are denied. Therefore, I’m no longer suggesting that.

However, claimants who sign POFs promising to repay overpayments should plan to do so, and avoid any voluntary lien issues.

Mass Mutual continues to harass my doctor with requests for psychotherapy notes. What now?

Discuss the vexatious requests with your mental health providers and ask them to  respond to Mass Mutual what their intentions are regarding releasing actual notes. Most mental health providers I’ve spoken to recently tell me, “I don’t take lengthy notes”, or, “these notes are for my benefit only. If I want to support someone for disability I’ll do it separately in summary form. I don’t release my notes.”

Mass Mutual has a few strange ideas about therapy notes to begin with. Recently, it communicated to a client that he, “should insist that the notes be given to him so he can provide them to the company.” This is a very dangerous idea. I have been working with mental health providers for nearly 25 years and in that time not one released actual patient notes directly to the patient.

Imagine how some patient notes could upset patients enough to cause them additional stress, worry, and angst sufficient so that they would try to hurt themselves. It’s just not done. In this regard Mass Mutual doesn’t know what it’s talking about.

The company actually said it will not pay this client if his therapist won’t give up the notes. If the notes ARE released, Mass Mutual will engage in a practice called “snatching” and will lift out of the notes all mentions that are adverse to the insured at the expense of all else in the record supportive of continued disability.  In this respect insureds are in a “damned if I do, and damned if I don’t” situation.

Mental health patients should discuss with their therapists and providers what should be done when requests are made for actual patient notes. Most therapists today regard their notes as proprietary and won’t release them anyway.

I’m not very happy with my Unum claims handler. Can I request that my claim be assigned to someone else?

Yes, you can ask, but my experience is that managers refuse to reassign claims upon claimant request. In so far as I’m aware, Unum doesn’t pay attention to much of anything claimants have to say that is contrary to the process, or the person handling it.

In addition, Unum has a useless complaint department that does not address or solve problems. You are much better off contacting the state department of insurance and asking their help in resolving problems with Unum.

In any event, Unum’s claims managers are NOT inclined to reassign claims upon request of the insured or claimant.

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Friday Q & A

Employee Resignations?

Quite a few questions have been received by DCS, Inc. again inquiring about resignations. There is a very popular post on Lindanee’s Blog having to do with resignations – “Resignations –  A Disability No-No. Please use the search tool from the Home Page to find it.

In short, employees should never “resign” when leaving work for disability reasons. “Resigning” means “I quit.” Employees who are recommended by their physicians to stop working go out on medical leave, they don’t quit. There is a difference. For details please read my prior article as mentioned above.

What does it mean when my Unum rep changes so often?

For Unum frequent changes in claims handlers is normal and means that as a company Unum has a retention problem, although the tendency to frequently fire people causes part of the problem. Claims handlers are assigned anywhere from 150-250 claims as a “block of claims” and when they leave those claims must be assigned to someone else.

Most often at Unum, the new claims handler begins to manage newly assigned claims in different directions causing havoc and confusion on the part of claimants and insureds. Some new claims handlers are highly critical of the way the “terminated rep” managed the claims and suddenly claimants are hit with a barrage of new requests.

Not retaining experienced, qualified employees, and/or frequently firing them, always has been a part of Unum’s continuity problem. Please note, new claims handlers may appear on files when it is decided claims should be sent to the Extended Duration Unit. (EDU) Although this. used to be a good sign to insureds, today EDU claims are risk managed even when SSDI has been awarded.

In addition to the above, Unum insureds and claimants should be aware that Unum plays musical chairs with their employees making it very difficult to have one claims handler for the duration of the claim.

How do I ask my doctor for an extension of my STD?

Well….you don’t.

DCS, Inc. recommends that patients on disability provide their physicians with a copy of their job descriptions. Office visits should include discussions about what material and substantial duties (job tasks) you are unable to do. Physicians aren’t mind readers and disability is ALWAYS work related, even LTD.

When you talk about your job descriptions and what you can and can’t do, physicians usually come to their own conclusions as to whether STD should be extended or not. Keeping treating physicians informed of what you are physically or mentally able to do keeps everyone on the same page regarding validation of disability to the insurance company,

Talking openly with treating physicians about what you are realistically able to do, or not do may also prompt your physician to examine you more carefully. Always make sure your official job description is located in your patient file so the physician can refer to it at any time. Disabled patients should always keep their physicians up to date regarding functional capacity.

Unum offered me a settlement and then promptly took it back. Why?

In my opinion, Unum settlement offers are now used to open the door to extensive file investigations. In the past, asking Unum for a lump sum settlement was a safe option for any insured or claimant. However, that is no longer the case, and DCS, Inc. is no longer recommending Unum settlements as claim resolutions.

In addition, some claimants describe to me getting attorneys involved who attempt to over negotiate settlement amounts. Unum will NOT negotiate lump-sum settlements outside of court to any great extent, and will instantly withdraw offers if pushed by an aggressive attorney to up the ante.

Until the public has a better sense of what is going on in Unum’s settlement area, it’s a good idea to stay away from asking Unum for lump-sum settlements. Some time ago, I received a call from Unum’s newly terminated settlement director who informed me the financial department was being used to risk manage claims, something that wasn’t usually done.

One gentleman claimant reported to me that shortly after he asked Unum for a settlement the settlement rep requested his SSDI file through Lucens, then wanted a field visit (not required by his policy), and more recently requested an IME. Unfortunately, this claimant may lose his benefits because he asked Unum for a settlement.

This is an issue claimants and insureds need to be very careful of.

 

 

 

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Friday Q & A

Does it matter if I pass or fail my neuropsychological test?

This is actually a very good question because insureds often have grave misconceptions about neuropsychological tests.

To begin, neuropsychology evaluations are NOT pass or fail. A battery of tests, (also not pass or fail), is chosen and administered by the evaluator. The results of the raw data (tests) are compared to normative scales/values and then subjectively evaluated. In other words, the evaluators give their opinions as to what the results of the tests mean. It is for this reason that I do not consider neuropsychological evaluations as “objective review.”

So many insureds are worried about “passing or failing” the evaluation when the test does not do that. A neuropsychological test is a qualifying evaluation to determine mental and cognition problems, impaired memory, malingering, imagined symptoms, and a whole host of other mental and behavioral issues. It is never a question as to whether one passes or fails, but whether the individual exhibits signs of real or imagined disease.

Insureds may be equating a claim denial with a “failed test”, and benefit approval with a “passed” one. But, in reality neuropsychological tests are evaluative tools, not tests that are passed or failed.

I found Unum’s claims reps to be totally rude. What can I do about that?

Yes, I’ve been hearing that Unum’s reps are missing a few French fries from their Happy Meals lately. My experience tells me this happens when claims handlers are overly stressed to produce profit results that don’t exist.

However, information I’ve been receiving from inside Unum also indicates the company’s internal philosophy toward insureds and claimants changed to negatively presume everyone who files a claim is a fraud. New claims handlers are currently trained to “suspect” all information submitted.

Companies who support such negative perceptions of its own customers encourage rudeness, and disrespect among its employees. In my opinion, part of Unum’s problem is (and always has been) arrogance resulting from lack of state and federal regulation and oversight.

For the moment, however, we know that Unum is internally chaotic and negligent in administering claims. Rudeness from employees is, of course, an offshoot of that.

DCS, Inc.’s clients communicate with Unum only in writing thereby avoiding Unum’s nasty claims handlers and their rude comments.

Can I report Unum to my state insurance department? Will they do anything?

If you have an ERISA Plan and the jurisdiction of your policy is subject to ERISA, your state Department of Insurance may or may or may not help you. I recommend that you send your complaint to your state DOI and request that they do “a market conduct examination of Unum’s claim’s practices.”

The ERISA folks can also send a copy of the complaint to the regional EBSA of the US Department of Labor. The location and regional addresses can be found at the DOL’s official website.

I wouldn’t waste your time sending complaints to Unum. The company’s mouthpieces like Rick Joseph do not solve problems, but only respond with a 10-page “we did nothing wrong defense.” It’s a waste of time complaining to Unum.

 

 

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Friday Q & A

What percentage of pre-disability earnings do Individual Disability Income policies pay?

IDI policies do not pay a certain percentage of pre-disability earnings, only ERISA Plans do that. IDI policies pay the “Scheduled Amount” located on the first few pages of the policy. Because IDI policies are underwritten separately, the amount of benefit can be chosen by the insured as long as it does not exceed the “insured interest”. In other words, if a professional has income of $200,000 per year, he can’t ask for a benefit that exceeds that amount. Multiple policies providing “a profit” from disability often characterize the insured as “over insured.”

Therefore, insureds are given more freedom to choose their own benefit amount, (within certain actuarial guidelines), assuming of course, they can afford the large premiums that go along with it.

What replaces the Global Assessment of Functioning (GAF Score?)

The DSM-5 replaced GAF scores with WHO DAS 2.0, a questionnaire that can be administered by the patient to himself, or given by family members in addition to traditional therapists. My impression of The Who DAS 2.0 is that it doesn’t hold as much weight in the disability insurance world as the GAF score once did.

Does my employer have access to my disability forms and my file?

Well, that depends. Employers can, 1) purchase group Plans directly from disability insurers (wholly insured), or, 2) they can self-insure (or self-fund) their own ERISA Plans with a third-party administrator (TPA) to manage the process.

Employers who purchase ERISA Plans from group insurers may have access to the initial application forms because it is they who fill out the Employer’s Statement and send it to the insurance company. Some Employers offer to submit all of the initial forms for their employees, so of course, they see the initial forms.

Afterward, however, employers will not have access to medical file information and insurers take great care not to send, or communicate medical information to employers. Since the two parties to an ERISA Plan are the employer and insurer, communications will go back and forth, but specific medical information is not shared with employers and is generally kept private.

Employers who self fund, or self insure STD and or LTD, generally have access to all disability forms and medical information since it is they who are paying the benefits. Decisions to pay or not to pay can still be made by employers and therefore they can have access to employee file information.

Although disability insurers make an effort to keep medical information private, claimants should note that once a HIPAA Authorization is signed to release the records, they lose HIPAA protection. In addition, disability insurers are expressly excluded from HIPAA laws and have no accountability in law to electronically protect medical records. Physicians who provide medical information TO the insurance company are under HIPAA’s jurisdiction, but disability insurers are not.

 

 

 

 

 

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Friday Q & A

Do disability policies pay benefits when you are in jail?

In general, “No.” Most disability policies exclude payment of benefits when claimants or insureds are “convicted of a felony.” Other contracts simply say, “incarcerated.” The best way to verify is to read your disability policy to determine what it says exactly regarding benefits, jail, incarceration or convictions.

Does it mean anything to me if my Unum representative is frequently changed?

Unum often has a problem with retaining trained claims representatives. My experience has always been that once claims reps discover the true nature of the job, they often head out for better opportunities. In addition, Unum has regular “firings” of personnel and those claims reps also leave.

Unum’s claims reps are given blocks of claims ranging in size from 175-250 claims. When the reps leave (for whatever reason), the blocks of claims need to be reassigned to someone else, or given to new, inexperienced people.

What happens is that a “new set of eyes” usually begins an entirely different investigative direction for the claim, or it could just sit in someone’s electronic file until, “he/she eventually gets around to it.” I’m sure there are readers out there in situations when suddenly a new Unum rep has the claim and all of a sudden there are multiple requests for information, or worse, surveillance and field interviews.

From the claimant’s perspective frequent assignments to different reps upsets the continuity of claim management, and in the future causes the claims process to be even more complex and confusing.

Unum has never acknowledged the chaos created by frequent reassignment of claims. The company doesn’t seem to care if they have a retention problem, nor do they recognize the chaos created for insureds when reps suddenly disappear from the file.

Basically, Unum does what it needs to do to make a profit and insureds be damned.

Will Unum accept a payment plan for repayment of my SSDI overpayment?

Well, it might, but it doesn’t have to. If you signed Unum’s new Payment Option Form giving the company a voluntary lien on assets, Unum can authorize that lien and take whatever resources you have in your bank account to repay. Unum’s most frequent repayment method is to reduce your benefit to $0 until the entire overpayment has been recovered. You can still try to make your best deal with Unum and take your chances.

There are many posts on this blog dealing with the fairness of overpayments for both insurers and claimants. Unum, and other insurers, front you SSDI award money by paying 100% of your benefit while SSA claims are pending.

If you agree to pay Unum back, you need to pay Unum back. It is the responsibility of claimants to repay what is owed if they sign the Payment Option Form and agree to pay back any SSDI overpayment. Claimants can’t expect Unum to uphold their part of the Plan to pay benefits only to “stiff” them on the other end. DCS,  Inc. supports what’s fair and is enforceable via the policy Plan.

What is “doctor shopping”?

Most insureds mistakenly think that “doctor shopping” is something insurance companies do to deny claims. In reality, insurance companies AND insureds can both engage in doctor shopping for their own benefit.

Insurance companies “doctor shop” by repeatedly sending insureds to multiple IMEs until they eventually obtain medical opinions in favor of claim denials. Disability Management Services, Inc. (DMS) is infamous for sending insureds on multiple IMEs, a form of doctor shopping.

A deviated form of insurer doctor shopping is when insurance companies obtain IMEs favorable to insureds but then send back multiple questions (Addendum) to the same IME doc to “iron in” favorable reports. Apparently, if insurers keep asking the same questions IME docs will eventually give the desired answer.

However, by far the most common form of doctor shopping is when insureds continuously seek out treating physicians who agree to document what patients themselves think they have.

I can’t tell you how many times I’ve encountered claim situations where insureds present treating physicians with lists of unverified self-diagnoses and insist that the physicians sign their disability forms. When one physician refuses and orders his own diagnostic tests, patient move on to other physicians who agree to support what the patients think they have. This usually happens with Lyme disease and environmental symptoms from mold.

Both forms of doctor shopping are done as a means to an end by both parties. Insurers want IME physicians to support denials, while insureds insist treating physicians document self-diagnosed diseases. Any medical attempts to circumvent the claims process immediately removes accurate and fair assessment of impairment.

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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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