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While insurance companies are not particularly known for administrative excellence they are required to maintain an internal claims review process that encourages accuracy and objective, fair review.

Unfortunately, in the last 6 months or so, as a company, Unum is obviously attempting to herd chickens and having a hard time doing it.

Law.com defines negligence as “failure to exercise the care toward others which a reasonable or prudent person would do in the circumstances, or taking action which such a reasonable person would not.” In the last few months, evident in my consulting practice alone, it appears Unum’s claims handlers are punting at best to “do something” to move claims.

Normally, I attribute Unum’s administrative bungling to large backlogs of claims that makes it impossible for one claims handler to manage. Case loads of greater than 175 claims creates impossible backlogs that deprive insureds and claimants of fair and objective claims review.

Ten years ago when I was a claims handler I managed 250+ claims, but that was another day and time when reps were contract experts and could make claim decisions on their own without management validation. Today, increased case loads with untimely validation requirements creates impossible backlogs that are impossible to get to.

So, what’s going on at Unum that is chaotic and negligent? Let’s take a look.

  • Asking for the same information over and over again. Several of my clients have received requests alleging late information when documents were already provided. This is a clear indication that Unum’s poorly trained claims  handlers are not reading the files the way they should. One would presume a reasonable person would “read the file” to determine what information it contains before requesting the same updates and documents. Unum’s claims reps are NOT READING THE FILES!
  • Letters are dated several weeks prior to being received by insureds and claimants. It’s very confusing for insureds to respond to a letter they received on March 16th dated March 1st requesting information on March 20th. This leads me to believe that Unum and its communication center in Columbia, SC is behind or not paying attention to when it sends out communications. The company’s reps may be trying to back float this inefficiency by sending things to their website portal to make it look as though the communications are current.
  • Reps are sending out letters with template paragraphs that do not make sense to individual insureds/claimant’s unique circumstances. Unum insureds often shake their heads and wonder, “What does this have to do with  me?” Claims reps are supposed to pick and choose the proper templates from drop down menus, but obviously they aren’t paying attention when they add every template paragraph they find to fill up 5 pages of a letter. Common sense should dictate that “less is more” and what is written should be accurate to the insured’s claim situation.
  • Can’t find the right policy. In my opinion, Unum isn’t good about adjudicating the right policies, and clearly the company has lost track of amendments, rescissions, and reissues. How can Unum adjudicate a policy when they can’t find it? Amid “Drafts” and “Specimen” copies, Unum is remiss in not being able to produce in all instances the proper policy in force as of insureds’ dates of disability.
  • Documentation of inaccurate information. Never before have I seen such frequent evidences of misrepresentation of documented information conveyed in communications to insureds. Clients and frequent callers are reporting that much of the information Unum alleges it has is false.
  • Using the wrong Authorization to obtain psychotherapy notes. Obviously, Unum’s claims handlers have not been told that the company has a separate Mental Health Authorization to obtain M&N patient notes.
  • Using third-party, out-sourced medical reviewers who clearly subscribed to the insurance industry’s agenda of not paying claims. DCS, Inc. is receiving calls from those who attended IMEs having been denied the right to memorialize the evaluations. Denying an attending witness and/or audio recording of an evaluation is and definitive indicator of a paranoid company.

While these are only a few indications of Unum’s race to inefficiency, internal information also indicates the company is using old technology in the claims process. Apparently, Unum’s systems frequently break down, according to internal sources. Supposedly, the IT systems networks were sent to India, but I’m not sure that actually took place. If it did, there doesn’t seem to have been much improvement.

In my opinion, Unum is now equal to the other “bottom feeder” companies such as CIGNA, Aetna and MetLife in terms of not being able to provide a competent internal claims review processes that lends toward fair and objective review. Chaos is the name of game causing insureds to be confused, stressed out, and worried.

Instead, Unum and its claims representatives are showing more and more that they are definitely not the brightest crayons in the box! Welcome to the bottom rung of the ladder.



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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.


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Independent Medical Evaluation Bill of Rights by Linda Nee

As most of you are aware nearly all disability policies contain a provision allowing insurers to request an Independent Medical Evaluation as “as often as reasonably required.” What this means is that insureds are required to “show up” for the IME or risk having their claim denied.

In recent years, insureds and claimants have been subjected to horrible treatment by IME physicians, and have been asked to attend in less than safe and suitable facilities. Recently, a mental health insured was bullied, shamed, and brow-beaten by a Unum professional IME evaluator. The insured left the IME feeling depressed, and abused.

Therefore, DCS, Inc. has established the following IME Bill of Rights to which all insureds have the right to expect when asked to submit to an insurance-paid examination.


  1. Insureds have the right to schedule the requested IME at a date and time convenient and reasonable for them.
  2. Insureds have the right to recover all mileage and food expenses when traveling to and from the IME location; or, have suitable transportation provided to them.
  3. Insureds have the right to attend the medical examination with a witness or audio record the session. Refusal to allow a disabled person assistance during the IME is a violation of human rights.
  4. Insureds have the right to obtain a Curriculum Vitae from any IME physician prior the the evaluation.
  5. Insureds have the right to bring additional proof of claim to the IME session.
  6. Insureds have the right to be examined in an office that is clean, dust free, sanitized, and suitable for medical evaluation.
  7. Insureds have the right to be evaluated in a medical office  or facility which is in a safe and professional location of town within 40 miles of their residence, or in the same county of residence.
  8. Insureds have the right to be examined by a  physician with the same board certification or qualification as the insured’s treating physician, or a physician who is qualified by board certification to evaluate insured’s claimed disability.
  9. Insured’s physicians have the right to have input into the selected battery of tests when neuropsychological IMEs are requested; treating neuropsychologists have the right to approve the selected battery of tests which are consistent with diagnosing a claimed disability prior to the administration of the evaluation.
  10. Insureds have the right to ask questions and to have those questions answered by the IME physician.
  11. Insureds have the right to be treated and examined with respect and not shamed, bullied, or accused during the evaluation.
  12. Insureds have the right to request an ambulance should an injury occur during the IME caused by the IME physician. All medical bills related to such an injury should be billed directly to the insurance company.
  13. Insureds have the right to be examined by a physician who speaks and understands English.
  14. Insureds have the right to refuse contact with any physician who is not clean and presentable, smells, has not washed his hands, or proceeds with the examination in a rough, painful or unexpected way.
  15. Insureds have the right to expect the IME physician to have read their file prior to the IME examination.

Insureds should never allow themselves to be treated in an in humane or disrespectful way. All IME sessions should be journalized in narrative form and forwarded to the insurance company for inclusion in the file. Insurers may have the right to require IMEs, but they do not have the right to subject you to any evaluation which is not professional, clean, and in a proper permanent facility.

You have the right to add IME feedback to your file, and I strongly recommend that you do it.

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Current information suggests that Unum is working with state regulators to ensure a “no contest” fall out when cognitive claims are limited to 24 months. Misuse of the Mental and Nervous Provisions always was a characteristic of Unum Life, UnumProvident, and now Unum Group, so much so that the company is obviously making sure it’s on solid ground.

There is a large spectrum of disease that can be the cause of “cognitive” impairment from mild to the most severe. Some result from physical causes such as cognitive deficit from organic brain disease, accidents or injury, and even chemotherapy. Regardless of the etiology of cognitive dysfunction,

Unum and other insurers tend to allege the impairment is “self-reported”, or mental and nervous and limit benefits to 24 months. A large percentage of Unum’s 24 month limitations are without IMEs where cognitive difficulties can be detected and diagnosed.

Resultant decisions are occasionally nothing more than the action of a claims handler who decides to allege the claim is “mental and nervous” and should only be paid for a short period of time. Such decisions make Unum’s managers happy because coding a 24  month limitation decreases the financial reserve.

Attempting to manage a ”cognitive” claim is made more frustrating when insureds and claimants are limited in their abilities to think and respond spontaneously, as well as the ability to complete questionnaires, update forms and follow-up with patient notes

Because cognitive issues are often the result of physical disease, “cognition” should be regarded by Unum as more of a symptom than a primary diagnosis. For example, a client was diagnosed with severe encephalopathy from meningitis resulting in moderate cognitive deficits. The physical cause of disability is therefore the meningitis, not cognition and the claim should be paid to age 65 not 24 months.

However, it appears Unum is hell-bent on classifying physically caused cognitive deficit as “mental and nervous” for the sole purpose of limiting its liability. Cognitive deficit, whether temporary or permanent, caused by chemotherapy is the result of breast or liver cancer, not a “mental and nervous” diagnosis.

In addition, Unum’s reviewers seem to find convent truths when reviewing cognitive claims. Those who suffer from physically caused cognitive issues are often in behavioral therapy in order to provide rehabilitation concerning daily management of activities and short cuts to increase the capability of performing daily tasks.

Even though the “therapy” is  not behavioral in nature, Unum alleges that because the insured is receiving therapy from a mental health provider, the claim is subject to the 24 month limitation. This is an abhorrent misrepresentation of the insured’s cause of disability.

This is an issue that is likely to be ongoing with Unum. My recommendation to cognitively impaired insureds is to obtain a neuropsychological evaluations with clearly recommended restrictions and limitations that explain why insureds are unable to work.

Also, a bit of warning. Some insureds mention “cognitive dysfunction” in combination with physical disease a bit too easily, thinking perhaps the addition of cognitive issues will ensure payment of the claim.

This is wrong thinking. Once “cognitive issues” are mentioned, insurers zero in on that symptom alone and may come to the conclusion that the primary diagnosis is “cognitive” and benefits should be limited. A “cognitive mention” in a disability claim should be backed up with the results of a neuropsychology evaluation, or not mentioned at all.

It’s clear though that Unum’s current issues with cognition claims, resulting in the limitation of benefits to 24 months, is likely to continue whether misrepresented or not.

If you are having problems with Unum regarding a “cognition” claim, please feel free to give me a call.


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A decade ago most disability insurers paid HIV claims with little resistance or prejudice. However, with increasing  medical advances in the treatment of HIV/AIDS and the improvement of medications, HIV patients often live a  normal lifespan.

Unum, and other insurers target HIV claims, particularly those that were approved and paid a long time ago, in order to re-review medical disability consistent with newer treatments. Unum’s goal, of course, is to NOT pay HIV claims since the popular view is now that HIV/AIDS patients can return to work full-time without restrictions.

As a consultant, I developed an expertise in managing HIV/AIDS claims a long time ago when Unum’s initial targets were surgeons and other professional medical insureds. Today, Unum’s bias toward HIV claims is even more pronounced when it documents insureds with T-Cell counts of 200 can return to the work environment.

According to most medical resources a T-Cell count of 500 is accepted as a normal benchmark for those with HIV. Newer HIV drugs often produce T-Cell counts of 600-800 with no viral load in most patients. T-Cell counts of 200 and below are indicators that patients are susceptible to serious bacterial infections, but yet Unum denies claims alleging these patients are healthy enough to return to work.

It is also true that while HIV insureds have very good labs with the newer medications, they continue to experience symptoms and side-effects that preclude returning to work such as chronic diarrhea, peripheral neuropathy, cognitive deficits, fatigue, dizziness, unsteadiness etc. The physical ability to work is not entirely dependent on T-Cell counts and viral loads alone, and other symptoms should also be considered when determining physical work capacity.

HIV physicians also contribute to the problem by documenting labs with not much mention of continuing symptoms that are the real disablers in HIV disability. Therefore, it’s very important for HIV insureds to discuss residual symptoms that are difficult to manage on a day-to-day basis. Reasonably, HIV patients cannot work if they are having difficulty managing their daily activities of living, are fatigued, and are suffering from neuropathic pain.

Of course, Unum takes advantage of the possibility of higher T-Cell counts to deny HIV claims with little emphasis on residual symptoms that are more disabling than the diagnosis itself.

If you have any questions, or are having difficulties with Unum because of a HIV/AIDS claim please feel free to give me a call. Remember, Unum wouldn’t be targeting HIV claims if it were not having profitability success in doing so.

HIV claims need not be unfairly denied, but they will continue to be targeted by Unum for “quick hits.”

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Although I don’t do this very often, it’s time for a few claims managers, Unum counsel, or some power that is, to provide mentoring to their claims handlers regarding the use of the proper Authorization when requesting psychotherapy notes.

It’s come across my desk more than it should that Unum claims handler’s are sending mental health providers Unum’s general Authorization to request patient notes. Obviously, your claims handlers haven’t read the Authorization because in the second paragraph the Auth specifically says, “except this authorization does not allow for the release of psychotherapy notes.”

Although I have given this message to Unum in the past, claims handlers still have absolutely no idea that Unum has an entirely separate Authorization to Release Psychotherapy Notes. Perhaps a Unum Lead Specialist reader of this blog could do a mentoring session to make sure claims handlers understand the difference.

As for insureds and claimants with mental health claims, please give a copy of Unum’s general Authorization to your therapists and point out the (…) in the second paragraph. There IS NO AUTHORIZATION to provide mental health records with this particular Unum Authorization and records should never be sent.

Most therapists are now refusing to provide actual psychotherapy notes anyway, but if you are a claims handler at Unum and are managing claims, please make an effort to use the right Authorization instead of trying to pass off the general Auth as permission to obtain mental health records. UNUM’S GENERAL AUTHORIZATION DOES NOT GIVE PERMISSION TO OBTAIN PSYCHOTHERAPY NOTES. 

Please tell me you are not so uninformed that you do not realize you’re using an Authorization that says, “No Auth” to obtain something “with an Auth.” It looks as though Unum claims handlers use the general “no go Auth” to deceptively obtain mental health information that in reality it has no authorization for? Unum claims handlers need to stop doing this, it makes you look like a dunce.

Therefore, Unum counsel and claims managers who are avid fans of Lindanee’s Blog, please provide some mentoring to your claims staff and inform them about using the proper Authorization to obtain mental health records. Unum’s claims handlers should probably know better anyway.

Insureds and claimants – show Unum’s general Authorization to your mental health providers pointing out the Auth actually excludes permission to release mental health records. Unfortunately, some therapists do not read the Auth either. So please point out to them that should they receive Unum’s general Authorization, records are not authorized to be sent.

Psychotherapy notes should never be released without proper authorization.


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Everyone should know by now that Unum makes unannounced doc-to-doc calls to treating physicians to persuade them their patients can work.

In fact, there are several very good articles on the blog for you to read about this in detail. Although Unum is taking the flack for this particular case story, CIGNA and other insurers do the same things, often with the same outcome.

Let’s take the case of Marty D., who went out on disability due to FMS and CFS. After paying the claim for several months, a Unum internal medical doctor telephoned her physician’s office and spoke to an intern who has assisting Dr. T. with his practice. Without checking the patient file, or consulting with Dr. T. the intern informed Unum’s doctor that Marty was well enough to return to work, full-time, without restrictions.

With a full release on record, Unum informed Marty of the communication “with his doctor” and announced the company intended to deny his LTD claim. Upon investigation, however, Dr. T. became furious when it was discovered who actually spoke to Unum and what was communicated about his patient.

Subsequently, Dr. T. wrote a letter to Unum explaining the information given was from the wrong person and definitely not accurate. But, alas Unum was not listening. Instead, Unum wanted to know what made Dr. T. “change his mind.” Trying to convince Unum an error had been made was like talking to a worm.

All attempts going forward to explain the mistake were ignored by Unum and Marty is still in danger of losing his LTD claim. The claim is now in a Unum department called “Quality Review.” (We’ll talk more about this in another post.)

The point of this article, however, is that once an error is made either by treating physicians, or someone else in their offices, it cannot be corrected to equal the same level of credibility that information was given prior to the error. 

This is something all insureds should spend some time thinking about…..Once your doctor, nurse, or any other person in your doctors’ offices gives out information, it sticks like glue in your record and can cause claims to be denied based on inaccurate false information. Unum doesn’t care….it runs with the information false or not.

Although insureds and claimants have an obligation to provide “proof of claim”, including medical, financial and vocational information, they really do not have control over what or how insurance companies attempt to investigate claims, including doc-to-doc calls.

However, insureds DO HAVE CONTROL over what information is AUTHORIZED to be released and to be informed of who’s asking for it. Most physicians are now privy to the abuse of disability insurers, particularly Unum, and refuse to take calls from any insurance company. There are treating physicians, however, who still speak to insurance physicians at the peril of their patients.

All insureds should make it very clear to their treating physicians (all of them) that they do NOT authorize the exchange of patient information on the phone. In addition, a HIPAA Authorization should include a request to be informed of all parties requesting patient information and be allowed an opportunity to review the information before anything is sent in response. YOU have complete control over who obtains and sees your medical information – all of it, including forms completed by your doctors prior to faxing back to insurers.

To be clear, disability insurers have the right to investigate claims and obtain medical information about you when you submit a claim for disability benefits. Group LTD Plans as well as IDI polices have provisions requiring insureds and claimants to submit “proof of claim” when asked to do so, generally at their own expense.

Treating physicians have the right to respond, “I am happy to provide you with medical restrictions and limitations and patient notes, but these requests must be submitted in writing to this office. We do not accept telephone calls from insurance physicians. Your company will be invoiced for our time and use of resources.”

As a patient, you are in control of what information goes where and who’s asking for it. Your treating physicians need not speak with insurance docs on the phone, and you have the right to say “no” in the form of written authorizations that are placed in your patient file.

Some physicians continue to fax information without allowing their patients to review it regardless of the patient authorization given. This is a HIPAA violation. Worse than this, if patients can’t trust their physicians to only act within the boundaries of authorization, then it’s time to move on and find other physicians.

The restrictions of your given authorization should be communicated to all those who work in your doctor’s offices. You and your treating physicians should decide together how insurance requests for information should be handled, particularly doc-to-doc calls.

Unfortunately, errors made in reporting work capacity cannot be undone. The record certainly can be “corrected and augmented”, but once the wrong information is communicated by your treating physicians it is treated as gospel by Unum who won’t listen to reasonable explanations.

We’re coming up on 1st Qtr. now and Unum’s managers are running wild targeting, stacking the deck, and misrepresenting any information it can get its hands on including information given in error.

All insureds and claimants need to communicate their intentions to treating physicians so that Marty D.’s situation doesn’t become your playbook. If you have any questions about this, please feel free to give me a call.




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