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Insurance claims handlers are taking their good ol’ PTO time leaving insureds and claimants with unanswered issues and resolutions during the summer months. It’s not as though companies like Unum, The Hartford, and MassMutual can’t figure out how to replace vacationing claims specialists, but it sure looks like claimants are at the bottom of the priority list during the summer months.

Out of the office claims specialists are directed to turn their claim blocks over to a “buddy”, or someone else in their respective units. However, getting through for help is still a chore for insureds who contact insurers by phone. (As you know, contacting insurance companies by phone is not recommended.)

Making matters worse are claims handlers who leave on vacation without manually approving benefits on their pay systems. Insureds and claimants are left without monthly benefit payments until their reps return to work.

“Who’s watching the store?”, you might ask. Good question. Years ago so many Unum reps went out on vacation at the same time that Tim Arnold had to put his foot down and say, “No” to unlimited summer vacations. In my opinion, some one needs to do that again.

It’s beyond me that insurance companies can’t figure this out and still provide good customer service during the summer months. Worse yet, insurers aren’t providing adequate customer service at any other time of the year either. Like all corporations these days, customer service is a thing of past unless it’s coming from India or another non-English speaking country.

Insureds are recommended to ask for Customer Service or claims managers when claims handlers aren’t to be found. At some point, some one has to show up and answer the phones.

 

 

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As most ERISA claimants should know employer-provided Plans do not insure actual jobs, but only occupations. Benefits are payable for the first 24 (12, 36, 60) months when claimants are unable to perform the material and substantial duties of their OWN occupations. Thereafter, claimants must prove they are unable to perform ANY occupation in the national economy.

Between 9 and 18 months of paid benefits most insurers will perform what is called “an any occupation investigation” by performing a TSA (Transferable Skills Analysis). Unfortunately, the process is subject to the GIGO principle – Garbage-In, Garbage-Out.

In reality, the TSA process should be as follows:

  1. Insurer informs claimant the “any occupation” process has begun and requests updated medical restrictions and limitations from all treating physicians.
  2. New medical information is reviewed by RN walk-in, followed by a review and referral to a vocational specialist.
  3. TSA is performed using occupational software to “look-up” and determine if there are “alternative occupations” available that are “gainful.”
  4. If more than one occupation can be identified, claim is denied.

The process itself is full of, well let’s say, holes and mistakes. To begin, most claims handlers don’t bother to update medical information with current restrictions and limitations. This is why the TSA is subject to the GIGO principle since using old medical information gives inaccurate results.

Vocational reviews are grossly outdated. Occupational information from the DOT has not been updated since the late 1970’s, and yet the bottom feeder companies such as CIGNA, Aetna, The Standard, MetLife still use old vocational information to determine alternative occupations. Occupational reviews are rarely current, or up to date, and clearly “gainful” information is also not accurate.

DCS receives many phone calls and questions such as, “Can Unum really make me go to work for McDonald’s or Wal-Mart?”, and the answer is, “Of course not.” All ERISA Plans contain definitions of what constitutes “gainful” employment and those provisions must be adhered to.

The problem is, I’ve never seen the issue of “gainful” documented in any file where a TSA has been performed. It’s unclear whether the insurer considered “gainful” or not. The any occupation investigation can progressively become more and more inaccurate when old medical restrictions and limitations are used in combination with grossly outdated vocational and gainful information.

“Indexing” is yet another forgotten item that is never documented or considered. In an inflationary economy (which we are not experiencing), indexing can make a difference in outcome.

The results of the TSA often document unreasonable and burdensome outcomes. Suppose a Unum claimant was on claim for 15 years when a TSA documented the identification of “alternative gainful occupations” and the claim was denied. Realistically, the claimant does not have the skills to re-enter a competitive workforce; there is no credible resume work history; and it’s unlikely anyone over the age of 50 will ever really get hired.

Tragically, it doesn’t matter – claims are still denied because “alternative occupations” have been identified. Claimants need to understand that the “any occupation investigation” after 24 months is the insurers last great hope to terminate claims.  Therefore you can imagine what kind of lion’s share resources are dedicated to the process.  However, statistically, the probability of insurers being able to terminate claims goes way down after a negative TSA is documented.

It is also important to realize that the process of “any occupation investigations” needs to be managed. DCS, Inc. assisted claimants with at least 10 change in definition claims in the last 6 months and all clients continued with benefits beyond 24 months. Just “sitting there” waiting for insurers to make a decision isn’t going to produce favorable results.

Change in definition provisions are an adverse part of employer-provided ERISA Plans. It is important for claimants to understand the process and be able to manage TSAs to a favorable result.

 

 

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Friday Q & A

Where are Unum checks mailed from?

Unum’s checks are mailed from Columbia, SC. All communications into and outgoing from the company also come from Unum’s data center located in Columbia, SC. I understand Unum is in the midst of a chaotic reorganization right now, but so far it looks as though the checks will still come from SC.

What is a Life Waiver of Premium claim?

Most disability policies (and life policies) have a Waiver of Life Premium provision that excludes the payment of premium for life insurance while on disability. Policies also exclude the payment of disability premium while on claim.

Life Waiver of Premium provisions most often require insureds to be totally disabled from performing ANY occupation and therefore it is possible to get paid for an own occupation disability claim, but the Life Waiver is denied.

For example, during the first 24 months of a paid claim, the insurer pays for own occupation disability but doesn’t accept the insured is totally disabled from ANY occupation. Therefore, it’s likely that Life Waiver of Premium won’t be approved until the transferable skills analysis is done at the any occupation to determine if the insured is totally disabled from ANY occupation in the national economy.

Please do not get confused with “disability premium waiver” and “life waiver of premium.” Insureds and claimants do not have to pay disability premiums once their disability claims are approved. By the way, Life Waiver of Premium provisions can exclude premium payments for disability even if the life policy is underwritten by another company. It’s always a good idea to check your life policies to see if they have a Life Waiver of Premium for total disability.

Are insurance field interviews HIPAA protected?

Absolutely not. In fact, all records held by disability insurers are not protected either. Disability insurers are specifically excluded in the law as HIPAA “covered entities” and therefore, files at Unum or CIGNA, for example, are not HIPAA protected.

Again, even though Unum’s Authorizations are HIPAA approved, the auths themselves say that once the information is released it loses its HIPAA protection. Although HIPAA laws do not include disability claim protection, the medical records forwarded to insurers are protected. But again, once you sign an authorization releasing the records the first time, they lose HIPAA protection.

HIPAA actually doesn’t provide all that much protection for privacy of medical reporting. It just sets guidelines for the electronic transmission of medical records or medical information. This brings up the argument as to whether doc-to-doc phone conversations are HIPAA protected. In my opinion, they are, and that’s why many treating physicians are now refusing to speak with insurance docs.

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One of my clients received a request from Lucens, Unum’s newest SSDI file chaser, to sign a form called “Authorization for The Social Security Administration To Release Information.” On the bottom right of the Authorization is “Form SSA-L88-OP1 (06-2014).”

In examining the form carefully, it appeared to me that something was very, very wrong. To begin, the Social Security Administration doesn’t place its form numbers on the bottom right, but the bottom left of all of its forms. Second, if you notice all SSA forms have an “Approved OMB No. at the top right of the form. And finally, no SSA form has bar codes on the bottom and right side of the page; and when I searched for the form from the SSA.gov page it wasn’t to be found.

Last year I wrote to SSA requesting to know why Unum was allowed to use its own form CL-1155 to request SSDI files. SSA responded that any authorization can be used if it meets the SSA Guidelines for Authorizations. I had no objection to that because Unum numbered its Form CL-1155, and never misrepresented its proprietary form SSA form with an approved OMB No. In fact, this was good news since DCS, Inc. could create its own form for client purposes.

However, the Lucens form uses an SSA number and is suggesting to insureds and claimants that the form is an official federal form when it is not. This kind of deception really irritates me because it isn’t necessary. Lucens could number it’s form differently, the same way Unum did and no one would be led to believe the Authorization was a real SSA form.

Please don’t be misled into thinking the Lucens Group Authorization is an official SSA form because it isn’t. It appears to me Lucens created it own form which is OK as long as the company doesn’t format it to deceive insureds.

Let me remind claimants that they do not have to sign any Authorization giving Unum permission to obtain their SSDI file. You are permitted to keep this information private. If you are harassed about it, pick up your phone and call your federal Congressman for assistance. At best, don’t be misled by the Lucens Group form; it isn’t an official SSA form even though it’s numbered to make you think it is.

Not a great start of confidence in Lucens as Unum’s new file chaser.

 

 

 

 

 

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Friday Q & A

How can I challenge an insurance neuropsyche test?

Anytime an insurance company asks you to present for a neuropsyche test it is very important that you also either retain or inform your own neuropsychologist that you would like to obtain the actual test booklets and raw data (the tests themselves), for independent review and comment.

Although the  insurance industry tends to place neuropsychological tests in an “objective category”, the results clearly are NOT objective. Each insurance evaluator chooses a “battery of tests”, administers them, and compares responses to normative statistics and values in the national economy. Finally, the evaluators render an opinion as to what the results mean. Clearly, neuropsyche tests are NOT objective measures of disability, cognition, somatization, or malingering and should not be allowed to stand alone in anyone’s disability file.

Copies of test booklets, and raw data should be provided to your own independent evaluator for comment and rebuttal. If this is not done, the results will be presumed to be accurate and will stand in the record. All IMEs, whether neuropsyche or not, should be provided to treating physicians for rebuttal. Absence of comment from your physicians is presumed to be in agreement with the IME reports.

What is the percentage of income that IDI policies pay?

Individual Disability Income Replacement policies do NOT pay based on a percentage of pre-disability income. IDI policies always pay the “scheduled amount” indicated on the cover sheet of the policy. Therefore, IDI insureds are buying a fixed benefit (scheduled amount), with the opportunity of Future Option Increases at various intervals along the way.

People sometimes confuse ERISA Employer Group benefits that pay most typically 60% of pre-disability earnings with IDI policies that pay a fixed scheduled amount. IDI insureds may choose a level of coverage as long as the underwriting of the benefit doesn’t exceed actuarial guidelines for overinsurance.

In contrast, ERISA Plans pay a certain percentage of pre-disability earnings and employees may not choose their level of benefits except if the Plan is a welfare Plan and includes several levels of payment such as 50%, 60% or higher. Some employers may offer supplemental “buy-up” Plans as well, but benefits are always a percentage of prior income.

I can’t get ahold of anyone at Unum. Is Unum still a company?

I presume Unum is still a going-concern, however, I have been hearing from others how difficult it is to find someone to speak to. Settlement specialists are non-existent, and even attorneys are finding it difficult to get to the right people.

Unum has been chaotic for quite some time now. The company continues to terminate groups of employees while outsourcing a good amount of the claims process to other companies, and countries. There is very little about Unum that is reputable these days and no one should be surprised when they can’t find someone to speak to. I’m guessing it’s much worse than that.

Who is G4S?

G4S is an investigative agency retained by insurers to conduct surveillance and field interviews. Additional information about the company can be found online, but in short, insurers hire the company to conduct investigations.

Although the name G4S sounds like “you’re in for it”, I’ve found the company to be your everyday run-of-the-mill insurance investigative resource.

 

 

 

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Guardian seems to be staying in the news lately as the company’s focus on “credibility investigation” reaches over-the-top levels. While no one disputes the right of any insurance company to fully investigate claims, Guardian’s practices exceed investigation levels that would normally be required to determine insureds are “unable to perform their own occupations.”

A good case in point is the insured who was injured as a result of an automobile accident several years ago and who recently claimed disability due to various shoulder muscle tears etc. According to the information I have Guardian’s investigators actually hunt down the driver of the “other car” who promptly said, “the accident was no more than a fender bender and no one got hurt.”

Seems to me the “at fault” driver might have a conflict of interest in reporting a “no one’s hurt” accident, but I have to wonder why Guardian took this line of investigation. If the insured’s medical information certifies the insured’s inability to perform as a dentist today, then what would it matter what the driver of the other car reported?

Guardian also tends to interview ex-spouses, a deliberate attempt to sully insureds’ reputations and credibility. Investigators “show-up” to interview peer workers, or accost them in parking lots with requests for written statements. There does not appear to be any logical reason to investigate the way Guardian does, and in my opinion, it crosses the line of prudent, normal and customary disability claim review.

Guardian’s investigations always seem to focus on credibility in lieu of whether or not insureds meet the definitions of disability in their policies. The company performs complex financial calculations regarding “residual” disability even when insureds are not residually disabled. Misrepresentations of policy provisions are immediately apparent, with little expectation of Guardian reversing its position.

Guardian’s claim investigations obviously have set priorities to investigate to deny rather than investigate to pay. This is the primary difference between fair and equitable insurers and those who seek to discredit insureds at all costs. DMS, Disability Management Services, is also a company who often investigates “credibility” in addition to contract provisional standards.

I can’t tell you what’s happened to Guardian in the last several years, but it’s all been downhill. Professionals looking for private disability and business protection coverage should look more toward Northwestern Mutual products and avoid Guardian’s insane investigations.

 

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As a disability claims consultant I can certainly understand how it could happen that insureds become so angry and frustrated with the claims process that they can’t see anything else except to “make them pay” and “admit everything they’ve done to me.” Although “seeing red” when it comes to managing a disability claim is a common reaction to abuse, anger, rant and non-cooperation doesn’t move claims forward at all.

The fact is, the disability claims process IS frustrating, harassing, and comes at a time when insureds aren’t feeling well and find it difficult to put up with claims handlers who just won’t pay claims. Unfortunately, once insureds really get angry, everything insureds do or say becomes suspect and claims fall into what seems like a bottomless pit of going nowhere.

Some insureds actually act counter to provisions that specify their obligations to meet criteria of Plans or policies. Not too long ago DCS was forced to fire a client because he refused to arrange to go to an IME despite my recommendation that he should go. This particular insured also did not provide the insurance company with the “whole truth” and therefore I could not continue to assist him. The reason? According to this insured, the insurer (Northwestern Mutual) was dishonest and was trying to “trip him up.”

In addition, we’ve come across some claimants who suspect everything, demand repeated proof, and accuse insurers of “lying”, and engage in “letter wars” that also gets them no closer to claim decisions. Most of my readers know I would be the first one to tell you that disability insurers are dishonest and delay or deny payment of claims. At the same time, constantly arguing small “who done it” points is trivial and in general puts insureds on a merry-go-round they can’t easily get off of.

Although insurers should base their investigations and opinions only on the unique facts of claims, there is credibility and “appearance of honesty” suspicions that arise referred to as “red flags”. Constantly contacting claims handlers (remember we do not recommend communicating by phone), and arguing, or engaging in “letter wars” isn’t productive to the claims process and will most likely produce denial decisions.

Therefore, while I validate anger reactions of insureds and claimants to the disability claims process, I certainly do not recommend engaging in constant rants with insurers. Recently, a new client came on board with major issues concerning Guardian. By the time he made a call to DCS he mistrusted everything the company did to date, had not been paid, and was in tears during most of the call.

During our conversation he reiterated that he wanted “proof” of this, and “admission of wrongdoing”, and “statements in writing” etc. It also became apparent during the call that his impairment was due to Bipolar and cardiac issues. One thing was certain – he was so mistrustful of Guardian and had been harassed to the point of desperation by the time he contacted DCS, that his only motivation was to “make them pay for what they did to me.”

“I want every damn thing they owe me”,  he said, “and I want to put them out of business.”

The unfortunate missing part, however, is that this poor insured still had not been paid benefits due to him. Within several days, DCS was able to work with the insured to the point that together we were able to support his claim medically, and he received a $40,000 check in the mail. I could not get him to stop crying.

In this case I think Guardian brought most of the anger and suspicion upon itself by demanding a field interview with both the claims handler and a field investigator (Guardian calls them “Technical Consultants?’) showing up to ask questions of someone diagnosed with Bipolar Disorder. Of course, this interview wasn’t going to go well and it didn’t. This is an example of what I mean when I say, “disability insurers know very little about disability.”

Also, well-intentioned, but inaccurate information provided by friends and neighbors can also incite one to wrath and isn’t always helpful either. Insureds who file disability claims need accurate information about the claims process, not opinions from those who really aren’t “in the know.”

Instead of acting upon anger, overreaction and suspicion, insureds and claimants should be more focused on “solving the problem” which in most cases is “paying the claim.” Insureds who find it difficult to calm down and act accordingly could benefit from having a consultant sort through what’s needed and getting the job done.

In any event, ranting and arguing with insurers doesn’t result in timely payable claims. Again, although I validate the feelings of anger and frustration with an impossible claims review process, I do not recommend constant suspicion on the part of insureds that makes them appear uncooperative, out of control and vindictive.

Ranting and arguing with an insurance company causes those who are reviewing claims to conclude, “the insured is crazy”, and creates “red flags” that lead to the lion’s share of investigation. While Unum might just laugh and go on investigating, Guardian is more apt to investigate more intensely and be suspicious of everything that happens moving forward.

Perhaps you may not have thought of this situation in these terms, but there are only two decisions insurers can make as a result of filing a claim – pay the claim, or deny it.

A successful outcome is when an insurance company pays benefits under the terms of the policy. Arguing and ranting and trying to get the reps fired isn’t going to give you the claim result you are looking for.

 

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