Archive for the ‘Q&A’ Category

What do I do after my claim is approved?

This is actually a very good question. If you haven’t already done so, you should get yourself a cup of coffee and sit down with your policy and read it. Insureds cannot defend what they do not know.

Second, all communications between you and your insurer should be in writing only – and, not on any website portal either. Give yourself some time to actually think about your responses by putting them in writing.

Next, answer only questions you are asked, and do not offer or volunteer any information. Finally, if you run into trouble, get help. Don’t wait until your claim is denied before seeking expert help.

Does smoking marijuana affect my disability claim?

Well, that depends. If you’ve consulted with a state licensed marijuana MD who has prescribed MJ to assist you with your symptoms, such as chronic pain, then “no”, smoking MJ will not affect your claim. States that allow medical MJ have procedures such as issuing a MJ identification card, and requiring a prescription to buy it.

On the other hand, if you’re buying MJ on the street and are using it as a recreational drug, it could affect your credibility and your claim. Smoking MJ purchased without a prescription is also dangerous when insureds are also taking opiate or other depressive drugs. In fact, any drugs you take whether prescribed or not, should be managed by an MD.

On occasion, insureds call me and ask for advice because they are using meth amphetamines while taking prescription meds. My advice is to either present themselves to the nearest emergency room, or share the information as soon as possible with treating physicians. Taking street drugs while on disability is dangerous as well as unlawful.

There is a big difference between “prescribed marijuana” and buying drugs from thugs on the street. Insureds should never use street drugs while on disability. This also goes for alcohol that might also have an overdose effect for some prescribed medications.

Who is the “claimant” when you’re on FMLA?

The Family Medical Leave Act is unpaid leave that runs consecutive with most employer STD Plans. FMLA forces employers to keep jobs open and health benefits paid for a period of 12 weeks. After the 12 weeks, employers have the right to terminate if the employee does not return to work.

Employers have a great deal of lead way these days in allowing FMLA go on for more than 12 weeks, but in the end, employers can terminate employment after the 12 weeks have expired, and, with the blessing of the federal government.

I always refer to FMLA recipients as “employees” when discussing FMLA leave. The word “claimant” refers to those who receive benefits under an employers STD/LTD group Plan. Remember, that the two parties to a Group Benefit Plan are the employer and the insurance company.

Employees who file claims are referred to as “claimants”, “participants”, or “beneficiaries.” ERISA requires that they be provided with an “SPD” (Summary Plan Description), which is usually the first page in a “Certificate Booklet”.

However, if you’re really asking about FMLA, the recipients should be referred to as “employees” and those who receive group STD benefits are called “claimants.” Because both FMLA and Group STD run consecutively, in most instances the word “claimants” can be used for both.

Why would Unum offer a settlement on a disability claim?

Unum never offers settlements unless they have exhausted all of their “risk management” resources and have determined the company is liable for benefits to the maximum duration of claim. This is a good thing right? On occasion, Unum may offer settlements to an entire “block of claims” such as New York Life because they want to eliminate the liability for that line of business from its Balance Sheet.

In most instances, Unum is looking to eliminate the claim while at the same time making a 20% profit. The company’s practice is to not offer settlements greater than 80% of the financial reserve. Therefore, at least a 20% profit is realized on every settlement, give or take.

Unum never does anything unless it’s profitable. Always follow the money when trying to understand why Unum does what it does. Settlements are no exception.


Read Full Post »

Friday Q & A

What are the most important things I should know if I decide to manage my own claim?

Never speak verbally on the phone to any insurance representative. Insist on all communications in writing. Don’t OVER SPEAK your claim. Know how to “position” your claim on forms, questionnaires and in your written correspondences. Never respond to insurers without contractual or Plan back-up. Know when you need help. Recognize the limitations of attorneys in case management.

What is the claims review process for STD? I’m having a hard time.

In the past, STD was automatically payable, and to my knowledge most insurers didn’t maintain financial reserves for STD – no profit potential there. However, insureds have now recognized that denying STD claims reduces liabilities for LTD.

The process always was a “stop-start process”. Insurers pay for brief periods of time, perhaps 2-3 weeks and then request additional patient notes, and pay for another 2-3 weeks. Therefore, it seems to claimants that they are perpetually chasing down patient notes in order to get the next check.

STD denials also mean LTD denials, a more expensive liability to pay. In 2017, insiders told me that Unum, for example, was handing off quite a few claims as Workers’ Compensation claiming “sickness” was in fact the result of workplace injury. Bottom line, insurers are continuously looking for reasons to deny STD to rid the company of much more costly benefits such as LTD in the future.

STD is in fact, a “stop, start process” to maximum duration, usually 26 weeks.

What is the difference between a “Waiting Period” and the “Elimination Period?”

A “Waiting Period” is the amount of time a new employee must wait before given the opportunity to enroll in the company’s group benefit Plans. Although for most employers the “Waiting Period” is the date of hire, some employers set up time conditions such as  “the first day after the end of the second month of employment.” A waiting period is relevant to new employees “waiting” to become eligible for group benefits.

An “Elimination Period” is the amount of time for which benefits are NOT paid beginning with the date of disability and ending on the last day specified in the policy. Elimination Periods can be 30, 60, 90, 180 and 365 days with the most common being 90 days. The 1st day after the Elimination Period is called the “first benefit begin date”.

Who actually makes the decision to pay or not pay claims at Unum?

Claims managers ultimately “validate” claims decisions, not only at Unum, but for most other insurers as well. Talking to claims handlers is like trying to communicate with robots who’ve lost their batteries, or who aren’t plugged in. In fact, I’ve described Unum’s claims handlers as little more than glorified administrative assistants.

Claims handlers do not have the autonomy to make claims decisions without the buy in of a manager who likely has access to financial reserves. I wrote several posts about how Unum’s managers delay claims decisions until they can manipulate financial reserves to meet unit profitability targets.

But no, Unum’s claims handlers are the lowest rung of the ladder and have been deliberately dumbed down for deniability sake.

Read Full Post »

Friday Q & A

Is FMLA self-insured?

Actually, FMLA, which stands for the Family Medical Leave Act, is neither insured nor self-insured – it is a federal law.

FMLA is law that requires employers to hold your job and continue to pay your benefits (not wages) for a period of 12 weeks. Essentially, it is unpaid leave that runs consecutive to Short-Term Disability. Some employers voluntarily extend the 12 weeks as part of their total employee benefit plan, but at the end of the day, employers can terminate your employment anytime after the elapsed 12 weeks with the blessing of the federal government.

Employers are required to notify employees of the termination and offer COBRA to replace healthcare. This insurance is very expensive because “COBRA” really means that the employer continues to include the employee in their group health plan after termination but charges a 40% or more surcharge to do so.

In any event, FMLA is unpaid leave mandated by law and is not “insured” at all.

Are “indexed earnings” the same as a COLA?

No. In fact, these are two separate definitions in the disability Plan or policy. Notice that we have “indexed earnings” which has nothing to do with benefits. In short, “indexed earnings” calculations are only used to determine “gainful occupations” as part of the change in definition investigation, or in residual calculations for someone working part-time. The key word here is “earnings” which distinguishes it from added benefits.

A Cost of Living Allowance is an additional benefit mentioned in Plans and policies to compensate for inflation. ERISA Plans rarely include a COLA because the premium is more expensive to employers, but IDI policies often contain COLA provisions.

What is “regular care”?

Regular care means that insureds and claimants are required to consult, or see their treating physicians, as often as is reasonable for the claimed disability. For example, an insured diagnosed with cardiomyopathy may need to consult with his/her cardiologist a minimum of once per month while another insured with post laminectomy syndrome might see a physician every other month.

Insurers always review claims to determine if insureds are in “regular and appropriate care”, meaning they are consulting with physicians with appropriate specialties, in addition to seeing them on a regular basis.

Having a paid disability claim requires all claimants and insured to be under the regular care of qualified physicians. Dropping out of regular care is a legitimate cause for claim denial. If you have any questions regarding what is and isn’t regular care please give me a call.



Read Full Post »

Friday Q & A

Can I return to work after I’ve settled my claim?

Of course you can. It’s interesting that I’ve been getting quite a few   questions lately about settlements and what insurers can do to them after they’ve signed on the dotted line.

The only relationship that exists between insured and insurer is outlined in their Plan or policy. Once a settlement agreement is signed by both parties that relationship no longer exists, and there is no obligation for either party to do anything. I admit some of these questions are a bit worrisome to me because it shows how little some insureds really understand about their policies.

In some respects, it appears to me that insureds may become so used to being afraid that it becomes normal and often continues into the future. But no, insurers can’t come after you for anything once you’ve signed a settlement agreement because no Plan or policy exists after that time.

After a claim settlement, insureds can stop looking over their shoulders for surveillance, can work, and also engage in any physical activity their health permits. Fear is no longer a normal thing, or it shouldn’t be at any rate.

Unum offset my benefit for dependent SSDI I haven’t even applied for yet. That’s no fair! Can they do that?

Actually, “Yes”.  Unum can because its Plans and policies say it can. If anyone has this same question please look at the offset section of your Plan and find the wording, “….benefits received or entitled to.” In the past, Unum waited until claimants actually received the retroactive overpayment before coding the offset, but no more. In its recent initiatives to locate every nickel and dime it can, Unum’s policy is to calculate BOTH overpayments (Primary and Family Awards), expect payment of both (which you can’t pay yet), and then offset for both awards while reducing benefits for the unpaid overpayment.

Unum is actually very clever. Despite the hardship this causes to claimants, Unum profits by coding offsets not yet received. SSDI offsets reduce financial reserve and thereby contribute to profit. It seems that Unum never changes its tactics since a decade ago claims handlers were required to code “presumptive” SSDI awards prior to any actual award by SSA.

Unum is never concerned about “what’s fair”, but rather concentrates on profitability at everyone’s expense. This is one characteristic of Unum that will never change.

Am I allowed to work during the Elimination Period?

You should check your Plan or policy on this. Some allow you to work during the Elimination Period, others require you to be totally disabled.

Working full and/or part-time during the EP (if allowed) can require a complex set of computations since days worked won’t count toward satisfying the EP and pushes out the benefit begin date. Although days worked during the EP need not be consecutive, part-time days are only counted as part-time actual hours worked.

I cringe when I encounter situations with claimants working during the EP because I doubt very seriously whether claims specialists today know how to keep track and identify when the EP has been satisfied. Always check the Plan or policy before continuing to work during the Elimination Period.





Read Full Post »

Friday Q & A

When will my attorney get a copy of any surveillance video?

If you have an attorney I would hope that he/she would have informed you that you are not entitled to any claim information until such time as your claim is closed. And, no one wants to have a “closed” claim.

Although the ERISA folks are entitled to full disclosure, IDI insureds are not, although most insurers will provide copies of claim files when denied. A few insurers consider surveillance information as “confidential and proprietary” and won’t disclose it unless subpoenaed prior to litigation.

If you have an attorney for your claim, my advice is to ask the attorney who is charging you fees to discuss disclosure requirements for you, your claim, and your state.

Is there a Unum “Code of Conduct” for its claims handlers?

I’m almost tempted to say this question is a contradiction in terms. Although Unum (and all corporations) have statements of objectives and philosophy, there is no written code of conduct for the claims process. HOWEVER, insurance credentialing agencies DO have codes of conduct.

For example, your claims handler’s signature block may include credentials such as HIA, ALHC etc. These credentials are earned by testing by the Health Insurance Association of America. This organization DOES publish codes of conduct for those who earn the designations. The problem is that Unum claims handlers cannot live up to the codes of conduct while working for Unum.

This issue was tested out during Unum investigations prior to the Multi-Settlement Agreement when a very astute attorney by the name of Gene Anderson (now deceased), of Anderson, Kill and Olick in New York, contacted the Health Insurance Association of America and reported violations of its code of conduct by Unum claims handlers.

The HIAA threw its hands up in the air and didn’t want anything to do with the issue. The point is that Unum’s claims handlers with HIAA credentials cannot work under any kind of code of conduct especially since Unum continues to manage claims by deliberately targeting legitimate claims for denial.

So much for the contradiction in terms.

What is Unum’s Navilink and what is it for?

Navilink, Unum’s diary system, replaced “Genesis” to dumb-down documentation kept on each claim. After the Multi-State Settlement where Unum got nailed, in-part, because of its detailed documentation, it was decided that “less is more” and management implemented Navilink to keep tract of file activity.

The system is very basic and does not detail a chronological account of all claim activity. While Unum can boast having a diary system, the company was very careful to decrease the documentation to a science.

What do you think I should do to appeal my claim?

DCS, Inc. does not recommend that individuals prepare their own appeals unless they can’t find an attorney to accept the case. I realize there are claimants and insureds who do their own appeals, but only a small percentage of these are successful.

I recommend that you seek out an experienced ERISA attorney with proven successes in litigating disability claims. Personal injury is NOT the same as disability claim expertise by the way.

Negotiate the fees if you can, and let the attorney inform you as to the process. One thing I’ve noticed is that some insureds are reluctant to discuss what they want with their own attorneys.

Remember, they work for you, not the other way around. Some attorneys can be pretty arrogant, but find an attorney you like and one with proven disability claim litigation successes. The chance of your success managing your own appeal is very low, and should not be attempted.



Read Full Post »

Friday Q & A

Who is Nancy Ball? I think she was a doctor at Unum.

You are correct. Nancy Ball is another one of Unum’s infamous “claim killers”, probably one of the best and well-known. I worked with Dr. Ball by requesting her to evaluate a few of my claims. From what I witnessed she rarely wrote reports in favor of insureds.

After I started DCS, Inc. as a consulting business I saw her name in other files that had been denied by Unum. At that time she was acting as an independent reviewer and not an employee of Unum’s. Still, in my opinion, Nancy Ball was just another Unum physician who left her medical ethics at the front door when she entered the building.

What happens to disability benefits after the death of an insured?

Great question. Nearly all disability policies contain Plan or contract provisions referred to as “Surviving Spouse” benefits. Most call for the payment of 3 times the gross disability benefit to a surviving spouse, heirs or estate. A death certificate must be submitted as proof the insured is deceased. The insured must also have been disabled through the Elimination Period.

If there are no heirs, the benefit is paid to the estate (in some policies if there are no heirs the benefit isn’t paid at all). Any outstanding SSDI overpayment owed is deducted from Survivor Spouse benefits before payment is made. For most families 3 x the gross benefit plus any unpaid monthly benefit to date of death is paid.

Disabled insureds should always discuss the Survivor Benefit with their families and let them know where to find the policy.

What is “Waiver of Premium”?

ERISA Plans and IDI polices both contain “Waiver of Premium” provisions that stop the payment of premium when claimants go out on disability. It doesn’t make much sense for insureds to continue paying premium while receiving disability benefits.

Waiver of Premium isn’t a big deal for Group Plans since premium is paid for the “Group” and not the individual. For insureds with IDI policies, however, premium paid since the initial date of disability is refunded when benefits are approved. Usually, there is a separate check issued for Waiver of Premium.

Is Unum entitled to my Social Security Disability information?

Unum is entitled to receive a copy of your original approval letters showing the amount of your benefit, entitlement dates, and attorney fees. Beyond that there is no provision in any Plan or policy that requires claimants/insureds to sign Authorizations giving any insurance company permission to have copies of entire files including the names of Determination specialists, approval listing codes, and other information.

Besides, Lucens and Unum’s Authorizations are valid for 2 years. Why do these companies need an Auth valid for two years? You have no obligation to sign SSDI Authorizations giving away information relative to your SSDI application, appeals or awards. If you wish to keep your SSDI information private, don’t sign the Auths.

Read Full Post »

Another Friday Q&A

Who is Alan Neuren and Alex Ursprung?

These two doctors are old Unum “claim killer” physicians who   (during my employment with Unum) denied claims consistently with Unum’s agenda. I attended roundtables with these physicians and they were definitely part of UNUMProvident’s efforts to deny more claims in bad faith.

Although Neuren and Ursprung are probably both retired from Unum by now, every now and then I still see an IME or peer review report in a file with one of their names on it. Make no mistake, both of these physicians are paid by the insurance industry, received executive bonuses from Unum, and, in my opinion always have been complicit with bad faith claims practices. Again, in my opinion, they sold out their professions to Unum a long time ago.

Can I give back to SSA, or refuse the retroactive back pay from SSDI?

I don’t know why you would ever want to do such a thing. The amount of retroactive pay would still be included in gross SSDI benefits and taxable. Insurers would still expect the money back whether you kept it or not. In fact, if the retroactive payment isn’t received, your benefit would be reduced to $0. I don’t see any upside to making this decision at all.

If your desire to refuse the money is to prevent your insurer from having it, then it seems to me you’re shooting yourself in both feet, and cutting off your nose to spite your face.

Is Disability Management Services, Inc. a good company?

No it isn’t. In fact, DMS may not be considered an insurance company at all in some states. The company is more of an insurance “holding company” , or reinsurer than a bon a fide disability insurer.

There are only three possible outcomes from DMS – a claim denial or nonpayment of benefit, a settlement, or continued harassment in the form of multiple IMEs. One of my clients was forced to submit to 6 IMEs in less than a year in order to get her to accept a settlement, which she finally did.

DMS acquires certain “blocks of business”, risk manages them for a while and then attempts to “settle” them in some way. This is true of corporate holding companies that buy up other corporations, put a little money in them, and then sells them at a capital gain.

I have found DMS to be eternally suspicious and egregious. As I said, the one option you aren’t given by this company is to have benefits paid to maximum duration. Your claim is going out one way or another.

Can I ask The Hartford for a settlement?

Of course you can, but I’m not recommending it. The Hartford has some pretty strange ideas about how to go about offering settlement to include an intense investigation of the claim that may also require IMEs, field visits and surveillance.

In my opinion, a settlement is not worth losing your claim, which is what The Hartford would try to do before offering any type of settlement. In one claim circumstance that I am aware of, The Hartford requested an IME and nearly denied a claim because the insured requested settlement.

It’s best not to put all of your eggs in The Hartford’s basket at this time.

Why do you think I am receiving such a hard time from Unum reps?

New Unum employees are trained to assume that insureds and claimants are malingering thieves attempting to defraud the company. I was told by an insider that new employees are told to pull all of the “risk management” activities out of the bag because people who file claims are malingering.

I believe the attitude of Unum’s claims reps reflects the official philosophy of company management.



Read Full Post »

Older Posts »

%d bloggers like this: