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Unum’s ERISA group plans contain SSDI provisions requiring claimants to apply for SSDI and “keep the process going” to avoid estimates and early offsets. Claims handlers quickly become annoying because of their constant chasing for SSDI status updates to ensure offsets are taken and benefits are reduced soon after approval letters are received from SSA.

Of late, however, Unum is estimating SSDI and reducing benefits despite information provided to it by claimants that the process of applying for SSDI is continuing. Threatening letters are sent to claimants that estimated offsets will be taken if information is not received. Even when SSA update letters are received Unum is estimating offset reductions from benefits, which by the way, reduce financial reserve and contribute to profitability.

Simply put, Unum’s Plans do not allow Unum to offset benefits with SSDI offsets, IF the claimant is continuing the process of appeal though the Administrative Law Judge hearing, or is re-applying for benefits.

I received several phone calls this week from claimants who have been harassed by Unum for SSDI updates already sent only to have their benefits reduced for estimated SSDI anyway. Unum is not abiding by the Plan document that writes claimants can avoid estimates if they follow through with SSDI appeals and the process in general.

Is Unum misplacing proof sent to it by everyone, or is it more likely that taking estimated offsets is a deliberate focus to bolster its profitability for year-end? In addition, the really awful thing is that when claimants are denied SSDI benefits Unum doesn’t give the money back alleging, “it’s obvious you would have been awarded anyway.”

My money is on Unum having a deliberate focus to estimate benefits for SSDI in clear violation of Plan provisions. In one instance, one of my clients (with my assistance) challenged Unum’s SSDI breach of contract and demanded the estimate taken be returned to her with interest. It was.

When challenged on this issue Unum doesn’t have a leg to stand on when Plan provisions are cited as back-up. Again, Unum cannot, via most Plan provisions, reduce benefits with an offset for SSDI unless the claimant refuses to apply, or doesn’t continue the process through with at least two levels of appeals – reconsideration and Administrative Law Judge.

Unum’s arrogance in blatantly and openly breaching its Plan contract is astounding. Claimants should always check their Plan or policy provisions for what it actually says about any issue raised by Unum.

It’s getting to the point where the company can’t tell the truth about anything.

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ERISAFor those of you interested in ERISA it seems clear that for every proposed improvement in the law, there are two negative reverses for claimants.

Unum, of course is a primary challenger of the the many proposed changes that will even the playing field in a now extremely unfavorable administrative and legal dilemna.

I’d like to remind the US Department of Labor that during the Multi-State Settlement investigations, memos were found whereby executives such as Ralph Money and Harold Chandler specifically documented how the company was making $millions off of ERISA denials. Once again, it’s all about the money, and the DOL needs to realize that.

Unum’s lobby contends (lobby also extends to Congress by the way) that the new proposed changes are too cumbersome and costly, nearly to the point of forcing insurers to drop disability lines all together. Such fear mongering might win Unum strange bed fellows in Congress but unless the proposed changes go through next year, the door will be left open for Unum, and any other disability insurance company to continue to abuse ERISA Plan participants for profit.

Unum Group should be viewed as “the beast in the forest” for suggesting that the new proposed changes should not take place. How cumbersome and costly can it be to make changes in the claims process that are fair, objective and equitable for all claimants?

I’m suggesting that every ERISA claimant in this country should respond to the US Department of Labor with their case histories. (Unum claimants in particular.) A non-response from the public regarding these issues will place all ERISA Plan participants “up chits creek” allowing insurers to continue to abuse the process of review.

I find it particularly naive of any insurer to think they will EVER be able to sell another group plan while opposing the changes below. This issue belongs in the court of public opinion and the truth about Unum and other insurers needs to be told.

I’m not sure where  claimants can send responses yet, but when I know I will publish it here. If anyone else knows please send me an email and I will incorporate it in to this post.

I’m not surprised Unum is leading the pack of wolves opposing ERISA changes. There’s more money in cheating claimants than there is in being fair within the claims process. People need to respond to the call for comments and let the DOL know you support the changes and why.

Here are the issues and what you possibly could lose.

(Reposted from ERISAlawyer.com)

The Proposed Delay Of The Effective Date Of The Final Rule.  The U.S. Department of Labor (the “DOL”) has proposed a delay for ninety (90) days – through April 1, 2018 – of the applicability of the Final Rule which amends the requirements in the ERISA claims procedure regulations that apply to claims for disability benefits.  The proposal is here.

The Final Rule was published in the Federal Register on December 19, 2016.  It is currently scheduled to apply to claims for disability benefits under ERISA-covered employee benefit plans that are filed on or after January 1, 2018.

Expanded Requirements.  The expanded requirements pertaining to disability claims include:

  • Benefit denial notices must contain a more complete discussion of why the plan denied a claim and the standards it used in making the decision.
  • Benefit denial notices must include a statement that the claimant is entitled to receive, upon request, the entire claim file and other relevant documents.  Benefit denial notices also must include the internal rules, guidelines, protocols, standards, or other similar criteria of the plan that were used in denying a claim, or a statement that none were used.
  • Plans may not deny benefits on appeal based on new or additional evidence or rationales that were not considered when the benefit was denied at the claims stage, unless the claimant is given notice and a fair opportunity to respond.
  • Plans must ensure that disability benefit claims and appeals are adjudicated in a manner designed to ensure the independence and impartiality of the persons involved in making the decision.
  • If a plan does not adhere to all claims processing rules, the claimant is deemed to have exhausted the administrative remedies available under the plan, unless the violation was the result of a minor error and other conditions are met. This allows the claimant to proceed to court immediately, and the court will not provide any deference to a decision by the plan administrator when reviewing the case.
  • Rescissions of coverage, including retroactive terminations due to alleged misrepresentation of fact (e.g., errors in the application for coverage), must be treated as adverse benefit determinations, thereby triggering the plan’s appeals procedures.

Questioning The Final Rule.  Following publication of the Final Rule, various stakeholders and members of Congress asserted that it will drive up disability benefit plan costs, cause an increase in litigation, and in so doing impair workers’ access to disability insurance benefits.  Pursuant to Executive Order 13777, the DOL has concluded that it is appropriate to give the public an additional opportunity to submit comments and data concerning potential impacts of the Final Rule.  The DOL will carefully consider the submitted comments and data as part of its effort to examine regulatory alternatives that meet its objectives of ensuring the full and fair review of disability benefit claims while not imposing unnecessary costs.

The DOL accordingly seeks public comment on the proposal to delay the Final Rule, in order to solicit additional public input and examine regulatory alternatives.  If, based on the comments received, the DOL decides that it will implement the proposal, the amendments made by the Final Rule on December 19, 2016, would become applicable to claims for disability benefits that are filed after April 1, 2018, rather than January 1, 2018.

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The most popular views on Lindanee’s Blog are the articles concerning “Returning To Work After Disability”. Although insureds and claimants receiving LTD or disability benefits may be able to return to work in some capacity, resume preparation may be somewhat problematic especially when trying to explain “lost time” without jeopardizing jobs they are qualified to do.

Let’s face it. Returning to the workplace can be frustrating particularly if you’ve been on disability beyond the age of 50 and have “year gaps” in your work history. Those who have been on disability for years also need to position a return to work very carefully so that their interests can be protected under “Recurrent” provisions in their policies.

As a former Dean of Students and Faculty at a local college, it was very important to teach resume writing and employment skills to non-traditional students such as those training for second or third careers after raising families, or after periods of disability. Of course, just knowing how to position and prepare a return to work while still receiving disability benefits will be extremely beneficial to those who are able to return to partial or full-time work.

A resume is a prospective employer’s “first look” at your education, skills and experience and is the first step to ensuring employability in a competitive work environment. I’m often asked, “How do I explain my lack of employment for the 6 years I was on disability? What can I do to maintain my skills while I’m disabled if I want to return to work in the future?”

In order to be of further assistance to insureds and claimants, I will be offering resume preparation and return to work counseling to all DCS, Inc. clients free of charge. Those who are not currently clients can either become clients, or pay a separate fee for resume and return to work services. These services are available to those who are currently receiving private disability benefits and who would like to pursue a seamless claim transition to work in the future.

Please keep in mind I am not an employment agency and will not be able to find or guarantee employment.  Rather, my services will help insureds and claimants prepare to return to work including the preparation of a good, clear resume. The rest is up to you.

Resume preparation and return to work counseling is free to all DCS, Inc. clients. Therefore, if you are currently on claim and are thinking about returning to work in some capacity, please feel free to give me a call for more information.

DCS, Inc.  (207) 793-4593 or DCS@metrocast.net

 

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FearHave you ever heard the old saying, “Those who control your money also control you?” Although one could say this applies to most occasions in life, it is particularly true of private disability claims and the extent to which insurers use FEAR to transform disabled persons into dollar sign profits.

Lately, I’ve been hearing nervous insureds saying, “I don’t want to do anything to jeopardize my claim because I need the money.” Obviously, those who are receiving benefits fully recognize the “control” insurers have over them and are willing to do anything to ensure the “checks are in the mail.” Unfortunately, doing everything the insurance company asks does not a successful paid claim make.

In fact, in my experience those who refuse to “push back” and defend their claims, Plans and policies are more likely to end up with zero benefits at the end of the month. Saying nothing, doing nothing, OVER SPEAKING claims, and providing as much information as possible is a dead ringer for denied benefits.

Fear causes people to do and say things they normally would not do. The elephant in the disability room is that insureds and claimants need and want to be paid benefits, and insurers do not want to pay them. In the end, from both perspectives, it’s all about the money.

Sometimes insureds ask me, “Should I see this specialist?”, or “Should I have this test to keep my benefits?” Putting treatment and continuously changing medical care just to keep benefits coming in is a prime example of how far insureds are willing go to ensure the money keeps coming in.

My answer to these types of questions is that those who are disabled should put their health and well-being as the first priority and let the claim fall into place after.

Disability insurance policies, ERISA in particular, are adverse to claimants from the very beginning. Plans contain 24-month changes in definition, 24 month mental and nervous limitations, offsets, self-reported and subjective provisions, appeal timelines and discretionary authority. One could easily say that insurers have claimants by the cojones from the very beginning.

Not pushing back to defend what little rights you have doesn’t mean benefits will be paid to maximum duration. In fact, those who appear a bit too willing to cooperate and are over accommodating often creates red flags that buys the lion’s share of risk management activity such as surveillance, field visits etc.

Another example is the fact that insureds and claimants continue to speak on the phone with insurance representatives thinking, “they HAVE to.” Actually, there is no disability policy I’m aware of that requires insureds to speak verbally with any disability claims handler on the phone. (Have you read your Plan or policy? It’s true.)

Yet, I still receive calls from those who say, “I just spoke with my claims handler….I told my claims handier something and now I’m in trouble….My claims handler was so rude to me…..They asked me why I don’t just go back to work…..”

Disability claims “Best Practices” is for insureds and claimants to request all communications in writing. Those who are taking prescribed pain medications, opiates, or depression drugs should NEVER speak verbally with insurance representatives anyway.

One of the best ways to “defend” ones rights under a disability Plan or policy to ask for all communications in writing so that there is never a dispute as to what is said, requested, or documented in the file.

Nevertheless, fear causes many insureds to continue to OVER SPEAK claims on the phone by giving far too much information that can be used against them in the future. A large percentage of claims are denied citing “you said…….” as the reason.

Since disability claims are adverse to begin with, it makes sense that all insureds and claimants should defend their rights under Plans or policies by “pushing back” when  claim requests are burdensome, overbearing or harassing. I’m not talking about coming across as aggressive or arrogant, but politely setting the standards as to what is appropriate claims investigation and what is not.

Challenging medical “misrepresentations”, and “snatching” medical information from patient notes favorable to insurers while ignoring all else favorable to insureds should always be challenged and corrected for the record.

Not speaking up to defend what’s right is a sure way to a claim denial. Since private insurers have you by the “kishkes” anyway, it’s always a good idea to speak up and use what clout you have to protect your benefits from unfair denial.

Giving in to every request, every unfair demand, every out of contract misrepresentation doesn’t assure anything but a swift kick in the guts from insurers  who do not want to pay you.

 

 

 

 

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Friday Q & A

I’ve had many very interesting questions submitted to DCS this week. Thanks to everyone who submits questions that are most likely important to others as well. Since my readers are too fearful to provide support to each other via the comment section, I like to answer questions here as Q & A. If you have a question you’d like answered, please send me an email.

What are some of the things I need to know about Unum?

WOW! What a question. I’ll try to list a few for you here:

  •  As the renamed company of Unum Life Insurance and UNUMProvident, Unum Group has a history of unfair claims practices that can be verified by the Multi-State Settlement Agreement, Georgia Conduct Market Examination and the California Settlement Agreement.
  • Through its claims management, Unum deliberately targets specific claims and then “works” them through their internal claims review process with deliberate intent to deny at some future date.
  • Unum relies solely on internal medical reviews (including insurance defense outsourcing) as back-up for denials. Medical information submitted by insureds and claimants is omitted from consideration. The company also has a hierarchy of medical review that creates the “illusion” of credibility. Unum systematically stacks the deck against insureds by “snatching” certain key phrases in patient notes and records favorable to them, while ignoring all else in the record favorable to insureds.
  • Unum misrepresents policy Plan and contact provisions, and is often dishonest in other ways.

Although I could probably fill a book with details about Unum Group, please let me recommend that you Search the Blog for additional topics and you will find out plenty of detail.

How is appropriate care determined?

Typically, treating physicians dictate what “appropriate care” is based on their previous history of consultation and treatment with their patient insureds, although it is very rarely documented as “appropriate care” in the records. Most insurance companies accept that fact except for Unum.

On occasion I’ve seen Unum cases where it sends out threatening letters to insureds informing them that if they don’t get into certain care, claims will be denied. A good example is a claim where the insured was diagnosed with meningitis and encephalitis who now has residual symptoms of cognitive deficit. Unum threatened this insured that if he didn’t get into mental health treatment and counseling Unum would deny the claim at 24 months.

Clearly, the cause of disability was physical in nature and not subject to the 24 month mental and nervous limitation and yet Unum determined “appropriate” care to be behavioral requiring counseling therapy. DCS, Inc. assisted this insured in proving to Unum that it’s determination of “appropriate care” was inappropriate, and we were successful.

It’s important to remember that TREATING PHYSICIANS determine what is medically appropriate within the recommended guidelines of the medical community. An example of inappropriate care would be a person diagnosed with depression and anxiety being treated by a family physician; or, treatment outside the specialty of the claimed impairment.

If your physician fails to document what he/she recommends as “appropriate care” you can be sure the insurance company will, particularly Unum.

DMS is making a request for an IME. How does DMS work?

Disability Management Services, Inc. is a reinsurer who buys up blocks of business and assumes the risk of other insurance companies.

By definition, DMS isn’t really an insurance company itself, but more like a corporate holding company who buys up other businesses, put minimal money into them, and then sells them at a profit. State departments of insurance do not recognize DMS as an insurance company and complaints are usually handled with responses of, “we have no jurisdiction.”

There are only two possible outcomes for claims managed by DMS. Either the claim is paid and IME’d to death until it can be denied, or the claim is “settled”.  Again, reinsurers by definition won’t pay claims indefinitely so those insureds who think DMS will continually pay claims without problems are very mistaken.

In one year, DMS requested one of my clients submit to 5 separate IMEs that kept coming back in her favor. Finally, after two years my client agreed to a lump sum settlement in order to have some peace.

DMS will NEVER stop requesting outside evaluations until a report finally shows up in its favor. It is very important for insureds to recognize the goals and objectives of reinsurers as different from regular private disability insurers.  Claims handlers are far more aggressive as well.

Can I really sign away my ERISA rights?

This question reminds me of occasions when Unum used to send out letters asking claimants to “sign below” waiving ERISA timelines for appeal review. It would be very unwise for anyone to sign such a waiver.

It’s egregious for Unum to ask you to give your permission to waive ERISA timelines and I never recommend doing it.


ebooksPlease don’t forget my first Ebook “Settements” is available by clicking the link at the top of Lindanee’s Home Page “Ebooks”. My Ebooks are also available from my website located at: http://www.disabilityclaimssolutions.com.

I am currently working on Book 2 “Appeals” that I think most readers would find very interesting, particularly those who choose to manage claim appeals on their own without an attorney.

A third book is also planned by year-end on the subject of “Returning To Work After Disability” that includes information about preparation of resumes with missing work history. This will be an excellent guide for those with plans to return to work in the future.

Ebooks are free to DCS, Inc. clients upon request.

If you have any suggestions of topics of general interest please let me know by email:

DCS@metrocast.net

If you would like more information about becoming a DCS, Inc. client please feel free to call me at 207-793-4593.

Thanks.

 

 

 

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Friday Q & A

Can a person be denied health insurance or reimbursement for treatment of fibromyalgia and chronic fatigue?

While there are so many different versions of health insurance available the short answer to this question is that health insureds are entitled, or not entitled, to whatever the health insurance policy says they are entitled to.

I don’t think it’s unreasonable to say that most people don’t actually read their health insurance policies. However, everyone should make an effort to obtain and read their actual health insurance Plans so that there are no surprises in the future when emergencies occur. It is entirely possible that some health insurance policies may not cover FMS or CFS,  limits reimbursement for treatment, or increases co-pays.

The best pre-emptive solution to insurance problems these days, including health insurance, is to be a good consumer of insurance products by reading the policy before purchasing it and having a thorough understanding of what’s covered and what isn’t.

What is Unum’s Navilink?

Navilink is Unum’s internal diary system. In theory it is a type of SOAP NOTE diary system whereby all activities taken on a claim can be documented. However, if you actually read the Navilink entries you will see that there are quite a few blanks left in the claim program.

At one time Unum Life Insurance was a stickler for documentation. I can remember management telling the claims handlers: “If it isn’t documented in the file, it didn’t happen.” Some Unum managers actually taught their newbies that one should be able to pick  up any file and have a complete record of everything that took place in the review process.

Eventually, Unum’s management realized this kind of detailed documentation was discoverable shot Unum in the foot at the time of the Multi-State Settlement Agreement investigations, and management decided to advise claims handlers not to go over board with claim documentation.

Therefore, while Navilink seems to keep claim activities organized internally, the notes rarely assist attorneys and Plaintiffs with information of wrong doing – intentionally, of course. The same is true of Unum’s Benefit Manual that describes separate processes but does not explain how a claim is reviewed from Step 1 through resolution.

Navilink does keep track of phone calls, and basic review information but it is not the whole story of what goes on in the claims process. Just try to find details about a “roundtable presentation”, or who attended Team meetings and what the outcome was. This information is NOT documented in Navilink, nor is any other information that could be viewed adversely against the company.

While Navilink might be a good way to keep information organized internally it shouldn’t be regarded as a complete record of activities taken on claims. It isn’t.

Should I play golf when I’m receiving SSDI?

Oh boy. Here we go again.

It depends on what you and your doctors are reporting to SSA, or your disability insurer as to what your restrictions and limitations are and why you can’t work. As a disability consultant I’m of the opinion that there are very few insureds who would be able to play golf after alleging total disability, or if they were able to play golf probably have at least some work capacity.

Working is both physically and mentally healthy, and anyone who has work capacity should be working, not playing golf.

The physical activity of playing golf involves arms, legs, hands, shoulders, trunk and back, weight-bearing capacity, lifting, walking, stamina (even if you use a cart), and mental capacity to figure out all the variables (terrain, wind, slope) and recording an accurate score at the end.

I wouldn’t want to be the one to have to explain to an insurance company how I am able to play golf but can’t work because I have chronic pain, back pain, carpal tunnel, fatigue, muscle weakness, lack of physical stamina, keeping me from working. Insurance companies generally regard anyone who can play golf as having work capacity.

Several years ago there was a disability case of a semi-pro female golfer alleging FMS kept her from working and yet she played in a pro-tournament. Unum denied her claim, and probably rightfully so. Another insured claimed a Unum disability for back trouble but took a part-time job as a ski instructor. Unum denied that claim too!

Finally, CIGNA caught a claimant with chronic pain engaging in motor cross bike tournaments and denied his claim when he bragged about it on his FB page.

Whether it’s private disability or SSDI insureds should abide by the medical restrictions and limitations provided by their physicians and reported to insurers. If you can’t work due to a set of physical R&Ls chances are you can’t play golf, ski or do motor cross racing either. It’s just common sense.

 

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Finally, the first Learning Resource, Ebook “Settlements” is now available for purchase from the Disability Claims Solutions, Inc. website located at:

http://www.disabilityclaimssolutions.com

When you arrive at the website click on the Heading “Resources” and you will see a pull down menu. The first item is Ebooks and you can purchase the resource using Pay Pal.

“Settlements” has always been a very popular topic for DCS since I receive many questions per year about private settlements and buy-outs. The “Settlements” Ebook, written by Linda Nee, an expert in the area of disability claims, provides important information including Present Value, Future Value, Mortality and Discount Rates, investments and many other “thinking points” that are so important when making life decisions.

I hope the information is valuable to you. If you purchase this first Learning Resource please provide me with your feedback and suggestions for information that you were looking for, but was not provided.

Book 2, not yet available will be on the subject of “Appeals.”

“Settlements” is a 22+page PDF document that will be provided to you via email. Thank you in advance if you are interested in purchasing the “Settlements” Ebook. I hope you find it helpful.

DCS, Inc. clients will receive all of the Ebooks free of charge by request.

 

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