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Stop Watching meInsurance surveillance is routinely conducted by private disability insurers to “catch” insureds exceeding medical restrictions and limitations thereby demonstrating work capacity.

After all, what qualifies insureds for disability benefits is the definition of disability that states “unable [or limited] from performing material and substantial duties.” And, insurers are very carefully watching!

While insureds are well aware of the possibility of surveillance they do not often realize that the simple act of conducting surveillance is often enough to support claim denials. Or, so goes the story from the insurer’s point of view. Surveillance is always misrepresented regardless of whether insureds were “doing something wrong” or not.

The old “walking the dog” scenario is used by many insurers to allege that “walking a dog” indicates work capacity when in fact a 15 minute walk up the street is only a 15 minute walk up the street. While insurers typically conduct three-day surveillances, normal activity of daily living self-care, although permitted, is used against insureds when they drive to the pharmacy to pick up medications, or go to their doctors’ offices.

Incapacity for work, via a medical disability defined in a Plan or contract does not mean that insureds need to be housebound, in bed, with a comforter up to their nose, although insurance companies want that to be the case. When observed, insurers presume all insureds, must at least show some semblance of being disabled all of the time.

Years ago I had a Unum client who was so frustrated with multiple surveillances that he finally asked his children to fish out old granny’s wheelchair from the basement. He then sat in the wheelchair, complete with huge white bandages around his head, and had his kids wheel him down the driveway. Halfway down, he yelled out and fell out of the wheelchair and couldn’t get up. Amidst screams of pain his children had to pick him up off of the driveway so he could stumble back into the wheelchair. He actually put on quite a show!

When he told me what he’d done I didn’t support it, of course, because it wasn’t truthful. But, the incident did make a point. Surveillance is only credible when it is unknown to the insured. Insureds can put on any type of show they want when they are aware surveillance is taking place.

Insureds aren’t the only schemers either. A few years ago, another ER physician client reported to me that sometime in the middle of the night he was awakened by a loud bang in front of his apartment building. Living on the 5th floor with a balcony, he looked below to find a grayish looking van and what appeared to be a human body next to a bicycle on the side of the road. The driver was calling for help and shouting for the physician to come below and help the victim.

The physician considered. As a DCS client, he was well aware of what to look for. To him, the event seemed staged and unreal. He yelled down to the driver that he would call 911 and get some help. After several more minutes of panicked persuasion, it became obvious to the driver that the ER physician was not going to join him at the scene.

To the doctor’s amazement, when the sirens of the summoned ambulance could be heard, the driver quickly threw open the back of the van, tossed the dummy and bicycle into the back and took off. Obviously, the surveillance was staged to bring the ER physician to an emergency situation proving work capacity for his own occupation.

Finally, there are times when insureds themselves do not use good sense. There was a report that a young woman, on a ladder, with alleged back problems was observed putting up Christmas lights on a 25 foot tree in front of her house. Another report observed an insured putting a new roof on his house and nailing tiles with a huge hammer. A very unwise insured actually started to clean up his yard after a hurricane with a chain saw and was seen sawing up trees, carrying wood, and pulling branches off of his house. (How would a surveillance team be able to show up a half hour after a hurricane?)

Playing golf is always a bad idea, and yet insureds will complete 18 holes and not think a thing about it. Golf is a game that requires: standing, walking, pushing overhead, bending, concentration, strategic thinking, exposure to elements, fine finger manipulation, physical stamina, and just over all fitness. And yet, one of the most popular questions I’m asked is if insureds can play golf and still receive disability and SSDI. Ludicrous!

What insureds often forget, too, is that Murphy’s Law is always in play……”Anything that can go wrong, will go wrong, and at the worst possible time.” This idea that “I won’t get caught just this one time”, doesn’t always play out. The first time you get on a plane to see family in the middle of the Grand Canyon for two minutes is when the surveillance team shows up.

Insurance surveillance must always be viewed in its proper perspective. The majority of three-day surveillances are NOT evidences of full-time work capacity, although insurers might try to say that it is. Short surveillances do not capture physical capacity for full-time work, and clearly citing a “walking the dog” scenario is pretty desperate on the part of insureds. “Walking dogs” is very rarely cited by treating physicians as a medical restriction, and insurers know that.

Insureds who exercise good sense when they know they are being observed fare best. Unfortunately, surveillance will remain a common occurrence as long as claims exist, but at least insureds can act accordingly, but without the wheelchair of course!

 

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Unum swat teamI’ve received several calls this week from insureds and claimants who are unreasonably scared as “to what Unum is going to do to me…..”, “Will Unum come after me and reduce my benefit?”, “Unum gave me 30 days to connect with GENEX, I don’t know who they are”, “What will Unum do to me…..do to me….do to me…….?”

Believe me when I tell you that despite Unum’s strong-arming and carrying a big stick, there  is no such thing as the Unum police and no one is going to “come after you” if you don’t do what they say. Right now, Unum is threatening everyone because management is only 10 days away from 1st Quarter profitability results.

Employees in the claims department are working overtime to find vulnerable claims to deny. Unum is NOT a good place to be at the end of a profitability quarter. Managers are cussing and stressing workers to the point of tears.

Even so, Unum’s harsh, abrasive letters have insureds hiding under their living room sofas believing GENEX is going to show up at their doors and take their money, or cause harm in some other way. The paranoia I hear on the phone is out of proportion to what Unum can actually do. “They are so intimidating, are they going to come after me?”

Ah…actually “No”. Unum isn’t going to come after you. They will never take your house in the dead of night, kidnap your wife and kids, or steal your car. Your lawnmower is safe, and so are your trash cans lined along the driveway. There is no Unum police and the big bad men aren’t suddenly going to arrive and do you harm.

What is actually true is that Unum deliberately designs its strategies to instill fear. Even if it didn’t, I’m sure there would be insureds imagining the worst. As one insured told me today, “I can’t even sleep at night thinking of what horrible things Unum could do to me.”

However, what I discovered by listening to the insureds who contacted me is that nearly every person gave me inaccurate information concerning what they know, or don’t know, about the disability process. For example, “Why is Unum forcing me to apply for SSDI when I’m going back to work in the near future? Unum is pushing GENEX at me.”

All you have to do in this case is notify your Unum claims handler that you intend to return to work in the near future and wouldn’t qualify for SSDI  anyway. I continue to be surprised by the number of people who call me with grossly inaccurate information. No wonder insureds are scared as they can be when they are acting upon things that have nothing to do with the  price of oranges.

I know that being on disability is a perplexing and frustrating process, but be assured that Unum does NOT employ a Swat Team to come and snatch you in the dead of night. Just use common sense and try not to cross the line into paranoia, or at least, not right away.

The only thing Unum seems to be doing very well these days is scaring everyone!

 

 

 

 

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https://goo.gl/yuEDuc

I’ve been saying this all along, but now it’s official. Please pay attention.

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Hungry VultureDCS, Inc. received several calls in the last two weeks from distraught claimants who received notifications of terminated Unum claims. We are indeed heading toward 1st Qtr. profitability targets and Unum, in keeping with its prior strategies for terminating claims, is once again living up to its reputation as a “Hungry Vulture”.

First Quarter profitability is always a popular time for Unum to establish the momentum for the rest of the year. Quite a few people receive terminations prior to March 31st, which coincidentally is just after Unum employees receive their annual bonuses for living up to Unum’s denial agenda.

This year appears to be particularly egregious, and for me, bad news about Unum never seems to end. Terminated employees still contact me, and former Unum physicians continue to call DCS, Inc. looking for other work opportunities once away from Unum’s cultish practices and control.

Just last week a retired Unum physician whose name I have seen in the record many times, contacted me. He was able to verify Unum’s continued bad faith practices – in his own words, “particularly in appeals.” I’m never surprised when Unum denies legitimately payable claims.

I really feel awful for all insureds who have been on claim for sometime only to be contacted suddenly about a claim termination. But, the reality is that this is how Unum Group conducts its business. Patterns of practice and strategies generally do not stray far from the management tree, and many claimants and insureds suffer losses as a result of the targeting, “snatching”, and misrepresentations of medical information.

Please be aware that Unum claims denied from now through March 31st are likely the result of target planning for 1st Quarter profitability results.

 

 

 

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Bad dudesIt should not surprise anyone to learn that Mass Mutual in one of the many private disability insurers who do not have separate and objective offices to evaluate and review appeals. Requests for additional review are given to the same claims handlers and managers who evaluated claims and made initial wrong decisions.

Mass Mutual is primarily an IDI insurer who in the distant past provided fair reviews. In my opinion, however, is recent years, the company side-tracked fair and equitable claims review and replaced it with contract misrepresentation, and “stacked deck” claims review.

The company also appears to have lost control of the claims review process by becoming grossly neglectful and untimely with decisions. Claims handlers are assigned claims even when they are in and out of the office leaving claims sitting on the edge of their desks without appropriate actions taken to move claim decisions forward.

The issue of not having “a separate set of eyes” evaluating claims submitted on appeal is far more serious. But, let’s understand…..IDI or Non-ERISA claims are not “entitled” to an appeal in the first place. Employer Group ERISA claims are ENTITLED to an appeal, but not IDI insureds. This may be the reason why IDI insurers do not have separate departments for so-called “appeals” when technically insureds are not entitled to an appeal. Nevertheless, having the same bad faith claims managers continuing review after-the-fact seems prejudicial and unfair.

A word of caution. Mass Mutual’s approach to appeals is deceptive. In a recent case, the insured received a letter stating the written “appeal” would be forwarded to some one else and that contact should be made to that person. It was through contact with the Consumer Affairs and Ethics person that I discovered he had nothing to do with an appeal and was addressing only the complaint.

I verified with this individual that Mass Mutual does NOT review appeal situations in an independent department, but allows reconsiderations to be evaluated by the same claims  managers who have a conflict of interest in not correcting errors, negligence, or contract misrepresentations. It’s actually abhorrent to think that insureds have no fair remedy potential without litigation.

The Unfair Settlement Practices Acts always includes a statue that [paraphrased], “considers it bad faith for an insurer to force insureds to engage in lawsuits to obtain benefits they have already shown they are entitled to.” In my opinion, Mass Mutual’s avoidance of “independent review” violates this particular statute, which by the way is also included in the NAIC Model Acts adopted by most states almost verbatim.

In the past, mutual companies treated their insureds better than stock companies but no longer. It’s fair to say that Mass Mutual is no longer a quality insurer and, in my opinion, prospective buys need to be aware that the company does not review claims or appeals fairly.

ADDENDUM 3/19/2019

After pushing the claims handler to find out who actually makes appeal decisions I was told by one of the managers that the claim in question was sent to a “consultant” to independently review the claim on appeal. HOWEVER, the manager refused to tell me the name of the so-called “consultant”, which in my opinion makes the information less credible. How do we know the claim was actually reviewed by an independent person if the name of that reviewer is undisclosed? Seems a bit shady to me.

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SSB ApplicationsPeople are always emailing me asking if they can “get away with this”, or “get away with that” when receiving SSDI. I do not answer these types of questions because I do not support what is not truthful.

A reader sent me the below article and I thought I would pass it along. As most of you know I do not recommend using social media at all when receiving benefits. However, not everyone listens to good advice.

It’s important to remember that most people who apply for SSDI are in fact honest. However, those who are receiving benefits by fraudulent means threaten the continuation of benefits for those who ARE honest. This is equally true for those on disability.

Social media is not recommended for anyone receiving disability benefits regardless of the source.

I also have to add that my readers should note that this article comes from the New York Times and decide for yourself whether it is credible or not.

https://www.usnews.com/news/national-news/articles/2019-03-11/trump-administration-wants-to-monitor-disability-recipients-social-media-accounts

 

 

 

 

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Bad faithIf there still exists any optimistic prevailing thoughts that Unum Group learned their lesson via the Multi State Settlement Agreement in 2004, think again. Although not widely publicized (likely suppressed), there is evidence suggesting that in 2008 when the RSA reassessment of claims ended, Unum partied, re-grouped, changed its name, and now engages in bad faith worse than it ever has.

I am referring, of course, to a fairly recent court case (2017),  U.S. District Court for the District of Massachusetts, Ann Rosenthal M.D., vs. Provident Life and Accident Insurance Company; and Unum Group, Case No. 4:17-cv-40064.  Interestingly, the case also involved testimony by deposition of claims handlers and middle claims management employees from the Unum IDI Worcester office, some of which were terminated.  (Although the names of these individuals are listed in the case documents, I’m withholding them from this article.)

 Employee testimony in the Rosenthal case confirms that “Unum sets targets for claims closures of its employees and that Unum requires employees to focus on financial considerations of claims rather than whether a particular claimant, such as Dr. Rosenthal, medically and vocationally qualified for benefit.”

The Rosenthal case also cites Merrick v. Paul Revere Life Ins. Co., 594 F. Supp. 2d 1168, 1171 (D. Nev. 2008) when the judge’s decision slapped Unum’s hands very hard for continued bad faith and unfair claims practices. While Unum continued to argue that it reformed its wicked ways, in Merrick the judge reiterated that the “reality is that the bad-faith claims handling addressed by the RSA, continues to this day, despite Unum’s contention that the unfair practices ceased.”

As a former claims specialist I was particularly interested in the testimony of XXX (2017), who in his deposition stated he was handed status reports containing the insured’s name and  claim reserve figures. (By the way, Unum now refers to denials as “recoveries” and official status reports as “metrics”.) A Unum VP, XX (also terminated), gave reserve reports to her administrative assistant who then distributed the information that was later shredded. Actual testimony was, “After reviewing lists of claims, including information about reserves, names of the claimants and other information, he, XXX, discussed the expected “recoveries” with his subordinates and then shredded the documents.”

Testimony of the five employees terminated from the Worcester office completely contradicted Unum’s representations made in a letter dated January 31, 2017 to plaintiff’s counsel alleging Unum’s prior “offenses” are viewed as “institutional bias” rejected by courts and insurance regulators. Unum’s arguments that bad faith occurring a decade ago was not relevant in the administration of Dr. Rosenthal’s claim was not persuasive given the testimony of the five second generation whistleblowers.

Specifically, the Rosenthal case included “Weekly Tracking” Exhibits listing recoveries (terminations) and other statistical information such as LARs, or Liability Acceptance Rates. Termination rates exceeded acceptable LARs of LTD (78%-82%), IDI (80%-85%) and were reported as 105% in some quarters. Even claims on Reservation of Rights were part of the “metrics” since removing ROR status has a negative impact on reserves.

For me, reading the depositions in the Rosenthal case was like old home week. Nothing changed. After all of the ruckus of the 2004 RSA, all of the testimony of whistleblowers at the time, hundreds of depositions given (over 50 of them were mine) and cases won, Unum is still operating rogue without state oversight and regulation of its activities.

In  my opinion, Unum is operating worse now than its pre-RSA levels, with no accountability or regulatory conscience that the company was caught red-handed in targeting claims based on financial reserves and unfair claims practices.

It’s pretty obvious that Unum will never change, revise, or do away with its “biggest reserve bang for the buck” management style that leaves insureds devoid of “good faith and fair dealing”. All Unum employees are still pushed to terminate claims while the March 2019 bonus is held over their heads as a beacon to profitability and “exceeds” performance levels.

Despite the untrue assertions Unum’s counsel puts out there, cases such as the Rosenthal case, complete with employee testimony, point to continued bad faith and targeting of claims at the expense of insureds who are at the mercy of Unum’s bad faith operational style that considers profitability over the merits of cases presented for payment.

If there are any attorneys out there interested in the Rosenthal case, please let me know and I will email you what I have. As always, if any of the terminated Worcester employees want to speak with me my door is always open.

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