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MetLife is by no means the only DI insurer that abuses policy provisions to limit benefits to age 65 and avoid paying Lifetime benefits.

However, recently it came to my attention that MetLife is engaging in unfair claims practices in order to avoid payment of Lifetime benefits.

Policies that stipulate Lifetime payouts for Total Disability but only to age 65 for Residual claims are consistently “alleged” to result in the payment of benefits “residually” in order to avoid payouts for Lifetime benefits.

This is particularly true of the typical DI insured who also has investments in passive income such as rentals, land development and other partnerships. Although passive income is usually reported on Schedule E of the US tax return, legal tax avoidance in some cases may place portions of the income on Schedule C as self-employment income – a huge mistake for those with private disability claims.

MetLife’s mantra is to allege insureds had a dual pre-disability occupation such as a Dentist and partner in rental management. Therefore, any income from rentals appears as though it’s earnings and not passive income. “Earnings” results in the payment of Residual disability and therefore benefits are limited to age 65.

Are you following MetLife’s logic? The insured is limited to benefits to age 65 because he has “passive rental income” and can be said to be “residually disabled.” Although passive income is most often derived from investments, rents, royalties, copyrights etc. most insurers look to other investments to allege “residual earnings” even when they have to pay 100% benefits, residually for passive income losses.

Unum does the same thing but in distinguishing between Sickness and Injury. Both insurers are engaging in deceptive claims practices involving interpretation of information and contract provisions (without ERISA discretionary authority I might add.)

The solution, in the form of preventing this problem begins in the planning stage before DI policies are purchased as part of a total family future portfolio package. Policies that distinguish maximum duration for Total vs. Residual disability should be suspect to the point of limiting alternative passive income. Another solution might be to add Lifetime Riders for both Total and Residual Disability, and Injury and Sickness.

It is extremely important for DI buyers to consider future possibilities before purchasing DI products. In addition, it is clear that insureds should be very careful of passive income and how it is reported on yearly tax returns. The door is already open to abuse by most DI insurers in those policies that distinguish between Total disability and Residual.

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Attorney feesDCS, Inc. received six phone and email inquires this week from insureds and claimants WITH attorneys who have issues and questions concerning how their claims and/or appeals are progressing. Although I usually refer these callers back to the attorneys they pay fees to, when the third call came in I realized there might be a problem.

DCS, Inc. maintains a list of what I consider to be aggressive, experienced, and successful ERISA insurance litigators, including settlement negotiation. Beyond those on my list to whom I am very complimentary, I am most unflattering to attorneys in my articles because they are part of the problem, not the solution.

It is often difficult to find an attorney who will agree to take a case when monthly benefits are less than, let’s say $4,000/month. Some attorneys refuse ERISA cases altogether. Therefore, a large part of the ERISA population is usually denied assistance by the legal profession because there’s no money in it.

In addition, those attorneys who do accept the non-wealthy cases are usually unknowledgeable when it comes to disability claims, ERISA, and claim management. After all personal injury law is very different from disability appeals and ERISA.

Let’s face it, attorneys do what they do best – litigate, but when it comes to claims management they either do nothing, waiting for the claim to be denied, or do the wrong things. In my experience most attorneys are more concerned about lining their own pockets than they are managing disability claims – there just isn’t enough money in it for them.

Thus, when insureds call me asking questions because their attorneys do not seem to know the answers I have to ask the question, “How is it that an attorney could file 5 unsuccessful ERISA appeals and not know the policy was not preempted by ERISA? Or, an attorney doesn’t know the statute of limitations for torts in their own state? Why is this attorney accepting an ERISA appeal when their specialty is Social Security applications? Do I need to ask? It’s all about the fees.

Most insureds and claimants just want to have their benefits paid, not go to court. In fact, no one should want to be IN court with a disability matter since the odds of winning are less than 50%, resolutions are untimely, and attorneys can walk away with most of the monetary award.

Still, I’ve encountered several attorneys who forgo offers of reasonable settlement so they can litigate potential bad faith in the hopes of being awarded large punitive damages. What they are NOT telling you is that bad faith is hard to prove since it involves “intent” – the case could go on forever.

I really feel awful for those insureds and claimants who tell me they have already handed over large sums of money to their attorneys with little to nothing to show for it. To be clear, there are attorneys who are fair and work hard for their clients, but unfortunately they are few and far between. I am not referring to them, but to the hordes of attorneys who take cases and have absolutely no idea what to do with them.

The objective of disability case management is always to help clients maintain their benefits. It requires specific knowledge about the claims process and when and how to respond to make it more difficult for insurers to deny claims.

Those attorneys who choose to “sit on” claims until they are denied are, in my opinion, engaging in unethical conduct. And, those attorneys who don’t know what they’re doing shouldn’t take the cases in the first place.

One attorney I know of in New Jersey took the majority of the ERISA 180 days to review a claim file and then two weeks before the deadline told the claimant she wasn’t taking the case. Yes, attorneys are permitted to refuse cases but only when they have notified the insured within a reasonable period of time.

Another Boston attorney charges clients $600/hour for claim management. (This attorney should be able to prove a considerable success rate for $600/hour.)

Still another attorney tells clients, “You can’t afford me.” Finally, another attorney deliberately did nothing during the 180 day ERISA appeal period so he could go to court where he found most of his money. I could go on and on, but I’ll stop here.

Although I take no pleasure in holding the legal profession accountable for what they do, it is still important for insureds and claimants not to allow themselves to sign back/forward fee agreements that are outlandish for no work actually performed.

Thank you to the attorneys on my short-list of referrals for doing such a great job with the clients I refer to them. As for the attorneys out there who are taking insurance litigation or ERISA appeals and have no idea what they’re doing, please reconsider what is best for the insured or claimant in lieu of your bank account.

I guess I’m just funny like that……I consider what is best for the insured/claimant in providing them with assistance for the continuation of payment of their claims.

Revelation! No one really wants to go to court with a disability claim; insureds just want to get paid the legitimate benefits they are entitled to and are sometimes willing to give up nearly half of their monthly benefit in order to receive it.

 

 

 

 

 

 

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denial-cartoonToday, it is the trend of highly paid professionals to invest, or be involved in many different enterprises. Doctors, dentists and self-employed executives diversify their interests and receive income from many different sources such as K-1 income derived from Partnerships or LLCs, and other corporations including several sources of self-employed income.

While it may be considerably profitable while healthy to be heavily divested, it clearly may not be of benefit to insureds when filing a disability claim, particularly with Met Life. Issues of determining what income is “passive” vs. “non-passive” can quickly turn a total disability claim into a residual disability paying 50% or less of benefits.

Met Life’s review process includes a review (that takes a very long time to do) involving passive and non-passive income. “Passive income” is income for which the insured does nothing to earn and therefore is most often identified as investment or equity income. Non-passive income is “earnings” for which there are K-1s and W-2s.

Of course, Met Life’s method of identifying passive vs. non-passive income is its own self-interest for doing so. Paying half benefits for Residual Disability is preferable to paying 100% total disability. Met Life’s strategy is to allege it is “adjudicating” policy definitions without regard to passive and non-passive income.”

Still, insureds should be aware that Met Life’s ability to allege a duo-occupation with multiple sources of pre-disability income may wind up being an unexpected “Residual” disability claim rather than total disability.

Again, while it is profitable to have income from many other sources prior to disability, disability insurers have devised strategies to pay reduced benefits under the Residual provisions of the policy by misrepresenting what is passive and non-passive income.

If you have any questions about this, please let me know.

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There seems to be a great deal of confusion as to when the insurance company pays for medical information and when the insured or claimant foots the bill.

If the insurance company sends you, the claimant, regular and customary update forms to give to your treating physicians for completion, then you are required to pay the bill. In fact, most ERISA Plans contain specific language that claimants are responsible for providing “proof of claim” at their own expense.

HOWEVER, on those occasions when insurers send forms directly to physicians for completion, the insurance company pays the bill. In my opinion, physicians are cheating themselves from collecting fees for their time.

In reality, physicians should be charging insurers not only for their time, but for use of office machines (computers and photocopying), and office personnel in addition to the actual time spent in filling out the requested forms. Some physicians begin by charging $100 per request and then increasing the fee by $100 increments when multiple requests for the same information are received.

Treating physicians will often fax the insurance company an invoice for the required fee with a note stating that once the fee is received he/she will provide the information. Even physicians don’t trust insurance companies when it comes to payment.

So, the rule of practice is actually very simple – if insurance forms are sent to you for your normal update from your physicians, YOU pay the bill.

When forms, questionnaires, narratives or patient note requests are sent directly to treating physicians from insurers, the insurance company pays invoices sent to them by the treating physicians.

If your physician hasn’t been billing insurers for information requests sent to them directly they are cheating themselves out of fees for their time and use of office resources.

Please speak with your treating physicians and make them aware that any requests they receive directly from your insurance company are billable opportunities. I find that when physicians bill your insurers it keeps them from requesting (or losing) the same information over and over again.

Physician billing actually keeps insurers from harassing physicians for frequent information, and it keeps the insurance companies honest about obtaining only the information they need.

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Disability Resources

Please note the addition of a Resource Page at the top of the blog Home Page. These resources were sent to me by a reader and I appreciate the contribution.

If any of you come across other valuable and helpful resources I can add to the Resource Page, please send me an email and I will be happy to add them. I’m hoping these links will be of value for those who are disabled.

Resources may include links to disability health,  interesting articles, claims, food and diet,  physical fitness, retirement, money management, pensions etc.

Thanks in advance for your help.

 

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Nearly every disability insurer has their own special gimmicks to encourage insureds and claimants to do what they ask without question. I call them “Why Lies” because the insurance industry, or insurer is attempting to justify “WHY” they are doing what they’re doing with a deliberate “LIE.”

The top “Why Lie” on my list is this statement, ” …please submit the above requested information so that we can give your claim every possible consideration before making our decision.” Unum uses a variation of this statement every time it requests SSDI Authorization signatures to obtain SSDI files.

No disability insurer ever looks for information “to give your claim every possible consideration” since there is always a profit agenda involved somewhere. For example, Unum requests SSDI files in order to obtain listing codes (Form 831) to determine if SSA classified the disability as mental or nervous. Even when SSDI files ARE obtained, Unum disregards favorable decisions using the rationale, “Since we have more current information about your medical condition that was not previously available to SSA, we disagree with SSA’s approval decision and deny your claim anyway.”

Another “Why Lie”, also used by Unum, is “…we are requesting a field visit to give you an opportunity to meet with us and ask questions concerning your claim.” What? Since when are insureds and claimants overly anxious to meet with disability field investigators to have questions answered?

The real reason for a field investigation interview is so that the insurance company can have you personally profiled, and encourage you to feel comfortable enough to share information that could be used adversely against you. The management template of questions provided to field reps asks for the same information that you provided earlier in the claim history.

Unum also uses the same rationale to encourage insureds to speak with its representatives on the phone.

Finally, another popular “Why Lie” is, “…we’re requesting this IME to clarify your medical restrictions and limitations.” Clearly, this is untrue. Insurance IMEs are insurance defense strategies required for the purpose of obtaining what appears to be credible evidence that insureds and claimants are able to work in some capacity. Insurance defense IMEs are a million dollar a year industry bought and paid for to “further enhance insurer objectives” – if you believe the marketing materials third-party facilities are advertising on the Internet.

I hope by now my readers are smart enough to recognize a put-on when they see one. All disability insurance companies are profit motivated, and most operate to deny claims rather than pay them. And, they all document statements in their letters to encourage the unknowledgeable to do what they say regardless of the fact that the requests are often  out of contract or Plan.

Insurance companies tell “Why Lies”, but a smart insured or claimant should be able to identify the truth from any profit agenda. Frankly, the “Why Lies” do insult my intelligence as they should yours as well.

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All disability Plans and policies determine disability status by writing definitions of disability that speak to one’s “inability to perform material and substantial duties of your own or any other occupation.”

This statement is probably one of the most misunderstood in that most insureds and claimants fail to recognize the cited connection between medical impairment and occupational status. Disability Plans and policies always connect the dots between an employee’s inability to perform work and the medical cause precluding the functional capacity to do so.

Therefore, it makes sense that “restrictions and limitations” should be viewed in the context of “What provable medical fact is causing this person from continuing to work in his/her own occupation?” This is the only context in which insurers evaluate disability claims by identifying medical impairments that are severe enough to cause people to stop working.

Keeping in mind the connection between medical impairment and occupation, the definition of medical or mental RESTRICTIONS and LIMITATIONS is, “occupational duties the insured or claimant may never do” and/or, ” occupational duties the insured or claimant may do, but only to a limited extent.”

Are you beginning to see that all restrictions and limitations are occupationally related? I think more often than not insureds have a tendency to forget that disability benefits are based entirely on the inability to perform occupationally related tasks. This is why it is very important for insureds to provide treating physicians with Job Descriptions and have frank discussions about what he/she can and cannot do (on the job) prior to filing any disability claim.

In most instances, treating physicians also remain unknowledgeable of the connection. For example, Administrative Assistant, Nancy X. began having difficulty with repetitive keyboarding, and use of her hands due to diagnosed carpal tunnel. She and her physician reviewed her Job Descriptions and found that 60% of her 8-hour work day consisted of keyboarding and using the computer to produce documents.

The appropriate “restrictions and limitations” could say this, “This patient is permanently restricted from the job task of repetitive typing – a restriction. Or, the treating physician could document a “limitation” by saying, “Ms. X. is limited in her ability to perform repetitive keyboarding and typing to less than 2 hours in a normal workday allowing for frequent breaks. She is further recommended to wear her wrist braces while keyboarding.”

Roger N., a construction worker, was diagnosed with herniated discs and began experiencing chronic back pain at work. Roger’s physician noted that his Job Description required him to lift up to 50 lbs. frequently, and carrying 50 lbs. occasionally. Other occupational duties required the use of a nail gun, hammers, and precision equipment.

Roger’s physician accurately wrote the following:

“This patient is permanently restricted, (duty Roger may never do), from the job task of lifting as it relates to the occupation of Construction Manager. In addition, Roger is further limited, (Roger may do, but in a limited way), in his ability to stand > 10-15 minutes, or use construction tools and equipment without risk to himself or others. From both a medical and occupational perspective, this patient is totally and permanently disabled from performing the job tasks of a Construction Manager.”

The above written “restrictions and limitations” correctly informs the insurer as to why Roger is unable medically to perform certain tasks outlined in his Job Description. Again, many people mistakenly believe private disability is all about medical diagnoses when it really isn’t. Consider that there are many people who are diagnosed with illness who are able to continue working at varying levels. Medical diagnosis does NOT equal entitlement to disability.

In addition, many insureds are misled by the fact that insurers conduct surveillance and record “personal” activity. Still, when viewed internally, “personal activities” are always equated to physical functional capacity for work. Although walking the dog, for example, is a personal, non-work related activity, if observed, insurers can equate this to 5 METS of physical ability, usually considered to be at least “sedentary work capacity.”

Remember, sedentary work capacity is all that’s needed to identify alternative occupations when performing a “Transferable Skills Analysis” at the 24-month change in definition. Insurers may be going around the block to get the information, but it always winds up as a component of occupational work capacity.

Accurately described medical restrictions and limitations are essential to the process of reviewing and paying private disability claims. Job Descriptions should always be provided to treating physicians and dialog should frequently take place as to what specific job tasks you are unable to do. Treating physicians are not mind readers and, on occasion, need to be coached as to what restrictions and limitations are.

Restrictions and limitations are always job or occupationally related; and, medical R&Ls should address what job tasks are restricted and/or limited. Leaving out any mention of occupationally required tasks is only certifying to medical impairment, not disability, which is why insurers keep harassing physicians for more and more information.

If your claim lacks accurate medical restrictions and limitations it could be at risk. DCS, Inc. can help with this, but it is extremely important for insureds and claimants to fully understand the connection between medical impairment and occupational physical capacity for work or job tasks.

Including medical impairment without connecting the occupational dots leaves an incomplete claim that will be eternally investigated by insurers and eventually denied or terminated.

 

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