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Archive for the ‘Unfair Practices’ Category

As a consultant I’ve always held the opinion there is something inherently wrong with a disability insurer who sends a letter to an insured with inaccurate statements. In fact, some statements are so obviously inaccurate one has to wonder whether those who make them are qualified to review claims at all.

Mass Mutual recently sent an insured a letter stating, “…as a patient you are entitled to these [psychotherapy notes] records.” This statement is grossly inaccurate and I would have thought Mass Mutual would know better.

Very rarely will therapists and psychiatrists release their patient notes directly to mental health patients. It makes good sense not to do so since what is contained in the records could potentially be harmful to those who are reading them. In some cases, therapy notes have been noted to be the cause of patients attempting to hurt themselves and therefore, it is generally recognized that therapy notes should not be released to mental health patients.

In addition, therapy notes are regarded by mental health professionals as proprietary to them written for the purpose of “reminders” of what took place during therapy sessions. Therapy notes are NOT written for the purpose of verifying disability through mental health restrictions and limitations. Mental health providers now regard patient notes as private references for their eyes only.

Over the last several years those who provide mental health therapy have noted the misuse and misrepresentation of information by private disability insurers to the extent that they themselves have office policies not to release therapy notes to anyone. More often providing “actual psychotherapy notes” to companies like Prudential and Mass Mutual hurts insureds more than they help.

Here’s how:

Patient notes rarely document “affect” which is an observation of how the patient’s reactions are, (flat or normal), and therefore insurers use this omission to deny claims. Prudential, for example consistently states in denial letters that the therapist failed to comment on “affect” and denies claims just on that basis.

Most behavioral therapy does not require neuropsychological or other tests to diagnose clinical depression and many other anxiety states. Yet, insurers look for documentation of “objective testing” in the notes when most therapy does not require it, or there is a lack of psychological tests available to diagnose specific conditions. There is a non-acceptance of WHO DAS 2.0 (in lieu of the GAF Score) by insurers, and clearly isn’t considered “objective evidence.”

In other words, if the actual psychotherapy notes do not contain exactly what Prudential and Mass Mutual want to see, claims are denied. The expectation that all therapists document what is needed by insurers to evaluate claims is unreasonable and ultimately unfair.

In the past, Unum denied a depression claim because surveillance showed the insured having sex with his girlfriend in the woods. Patient notes were submitted to Unum but were not considered as compared to the surveillance. Therefore, according to Unum those with depression aren’t supposed to be having sex. What idiocy!

Recently, Mass Mutual threatened an insured with claim termination if he didn’t obtain his therapy notes and submit them. Mass Mutual’s claims manager told me personally, “Those records belong to him and he needs to obtain them and provide to us.”

The letter clearly said, “No additional payments will be made until we receive the daily treatment records from [your doctor]. What if this patient’s therapist refuses to release his patient notes? Should Mass Mutual penalize the insured because his therapist refuses to release notes? And, even if the psychotherapy notes were released, Mass Mutual (Prudential in particular) will allege the notes do not contain sufficient detail to continue to pay the claim.

Are you getting the idea that mental health insureds and patients are “clucked” regardless of what they, or their therapists do?

In any event, Prudential and Mass Mutual continue to insist on psychotherapy notes, which by the way, is an out-of-contract request. No where is anyone’s policy or Plan is there a duty or requirement to submit actual psychotherapy notes as “proof of claim.”

When I asked the Mass Mutual claims manager to fax me the page from someone’s policy requiring submission of actual psychotherapy notes, she gave me the run around and then said, “but our Authorization allows us to request them.” That’s true, Authorizations may request submission of notes, but that doesn’t mean the therapist is willing to release them.

Unfortunately, ERISA Plans often include the phrase, “…satisfactory to us…” which  permits “discretionary authority” to the insurer to decide what is and what is not “proof of claim.”

Mental health claims remain a constant source of controversy as insurers continue to deny claims for failure to submit actual psychotherapy notes they may not be entitled to.

Therapists should be able to submit mental health restrictions and limitations in summary form (filling out forms or submitting letters) rather than giving up patient notes not intended for the validation of private disability.

 

 

 

 

 

 

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Every disability claim has an assigned claim financial reserve, or future value cash flow set aside to pay claims. Financial reserves are recorded as liabilities on insurance company Balance Sheets, and eliminating claims produces immediate contribution to profit.

Of late, Unum has been aggressively managing claims with very low financial reserves, often spending more in risk management activities than claims are worth.

Recently, Unum began harassing a female claimant with a monthly benefit of $370/month with repeated medical requests, surveillance, phone calls and field interview requests. The total cost of the risk activities far exceeds the value of a claim with such a low benefit and only 3 years to maximum duration. Is Unum’s management insane? In the example given, the claim has less than $40,000 total in financial reserve.

The cost of denying such a low value claim far exceeds its value particularly in light of the fact the claim had already been paid for 15 years. For claims with such low reserve values, it is cheaper to pay them to maximum duration than it is to deny them.

Unum’s Plans often pay a minimum benefit of $100/month and still claims handlers are falling over themselves stacking the deck with information to deny. It does not make sense to me that Unum’s management would allow employee time and effort to be spent on claims with minimum benefits given the large back logs Unum seems to accumulate with much larger financial reserve values.

As an experienced consultant with claims exposure it appears to me the only reason why a disability insurer would go all out for minimum value claims is to show financial reserve gains at all costs – and I mean all costs. Does Unum have a cash flow  or profitability problem? Why is management making such poor claim review decisions?

Reports are increasing that Unum’s base of employer group products is decreasing. Since Group LTD is Unum’s core product, if the rumors are true, the company could be in trouble financially. It is also curious that large numbers of Unum employees are disappearing only to be replaced with outsourced services, most of them off shore.

I am also suspicious of Unum’s offerings of various types of group indemnity insurance to make up the for the loss of LTD core employers. Hospital indemnity and catastrophic insurance may be bringing in additional premium, but Unum doesn’t pay these claims any more than disability ones!

Finally, claim review specialists left behind are trained to assume all insureds and claimants are dishonest, and medical information provided by treating physicians is not to be trusted – all key criteria in identifying a bad faith insurer.

Is this really the type of insurance employers want to provide to their employees as part of their benefit package?

Frankly, I worked for Unum partly in its heyday, and partly in its decline. It’s sad to see Jim Orr’s “Lighthouse to the World” vision transition to the “Unum Group Outhouse” in 15 years. Unum’s demutualization in the mid 1980’s in combination with the 1999 merger ruined a good insurance company that now has to fire people, outsource off-shore, and deny legitimate claims to stay in business.

Who would have thought?

 

 

 

 

 

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What happens when a really awful disability insurer such as Unum Group engages in new strategies to deny more and more claims?

Recent information received from inside sources indicates Unum recently fired older workers and is training new, younger Specialists to assume all insureds and claimants who submit claims are doing so for secondary gain.

Vilifying insureds and claimants always was a Unum specialty so it does not surprise me that the company is once again (or still) focusing on new claim propaganda training. Years ago I described the training as “brainwashing” and clearly new Unum claims reps will be forced to do what management tells them to do rather than what’s written in policy contracts.

Most Unum employees won’t ever realize the disparity between how disability claims should be reviewed versus how they are actually viewing them. All employees are forced to participate in a claims review process that is unfair and harassing, but know clearly, “it’s Unum’s way, or the highway.” Employees who want to keep their jobs do what they are told and remain faithful to the Unum collective for a paycheck.

Word is that Unum management is also quietly doing away with entire work groups and sending internal departments overseas. I’m also told that internally Unum is masking the disappearance of work groups to give the impression they are still on campus. Why the deception?

What this means for insureds is that Unum’s reps will be managing claims in “high aggressive mode” assuming everyone is dishonest until proven otherwise. Inside resources have also suggested the “training” includes reviewing medical information with “focused selection” (my term) to interpret medical information in ways that are favorable to Unum. In my opinion, Unum Group has always engaged in false medical review evaluation so it’s hard to imagine the process getting worse.

Those with Unum disability claims will need to pay particular attention to differences between what’s true and what isn’t and swiftly take the necessary actions to correct the official record.

Also, as I indicated in my prior post, social media and Internet presence is out of the question. Unum’s website portal should also never be used.

It really is too bad, but inside reports about Unum are never good news. No wonder my resources describe Unum as, “same sleaze, different day.”

 

 

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Several years ago I wrote an article called, “Private Trespass” describing insurance company tactics that invade the privacy of insureds. The company that comes to mind is Guardian, a company known to have no regard for the personal privacy of those it insures.

A “private trespass” is when an insurance investigator or field representative shows up at a person’s home unannounced and demands an interview. They all seem to use the same overused line, “I was in the area and thought I’d stop by to see if we could talk about your claim.” Insurance companies must not realize we can all recognize the brown stuff when we hear it!

Guardian’s policies rarely include contractual provisions requiring involuntary submission to investigation interviews, but it’s investigators show up unannounced nonetheless on the door steps of insureds demanding to be let in.

This practice is inappropriate and is intended to catch insureds off guard and unprepared to audio record the conversation, have a witness present, or to choose an alternative location away from their homes. Guardian’s motive and malicious intent is obvious.

Insureds are not required to meet with field investigators if the requirement to do so is not in their policy contract. So, Guardian’s investigators simply show up anyway.

Those insureds who own their own property are recommended to place a small “No Trespassing” sign on their lawns so that the police can be called if unwanted investigators suddenly show up. Those who live in gated communities can always leave word to not allow any strangers not approved in advance.

Those who live in apartment buildings can also ask management to put a small “No trespassing” sign somewhere near the entrance. If insurance investigators show up, call 911 and actually file a trespassing complaint.

The worst part about all this is that it really has the effect of shaking up insureds who are not prepared for this kind of private trespass. It is extremely unnerving to have an insurance investigator suddenly show up at your door. This is the exact reaction Guardian (and other unscrupulous insurers) are looking for.

You do not have to put up with having your privacy invaded by investigators who suddenly disturb your peace.

Put up a “No Trespassing” sign and then call the police! There is no need of this.

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While it is unfortunate that Lindanee’s Blog posts quite a few articles involving Unum Group, it is nonetheless true that of all of major US insurers, this company has a pattern of practice of engaging in unfair claims practices that are simply unconscionable.

In fact, I’ve written so many articles on Unum’s biased medical reviews that it should be clear to anyone that Unum is indeed the company of “No.” Unum’s multi-tiered medical reviews are performed by physicians who receive percentage bonuses to provide “claim killing” reports that do indeed misrepresent medical patient notes. In comparing patient notes to Unum’s medical reviews, there are times when it’s unclear whether the report is assessing the same claimant/patient.

Unum not only denied a legitimate payable claim today by misrepresenting medical information, but the claims handler cited Unum’s old scam-line about how the company obtains SSDI files to “give the claim all possible consideration.”

The truth is, Unum makes a big deal about obtaining SSDI files in order to: 1) obtain SSA listing codes associated with mental and nervous approvals, 2) obtain the name of the DDS (Disability Determination Specialist) potentially to remain in touch in a reporting capacity, and 3) to have access for 1-2 years by virtue of getting you to sign SSDI Authorizations that are valid for at least a year.

Unum’s internal medical reviews are deliberately biased and prejudicial against insureds and claimants for profitability sake. Performed by physicians who either can’t, or won’t work inside their own industry, Unum takes advantage of “board certified” credentials, although I’m told nearly all doctors today are “board certified.”

Unum’s methodology of subjecting claims to multiple internal reviews is seriously flawed since the first review deliberately always favors Unum and no other reviewers dare to disagree. In addition, it’s obvious in reading the recent denial letter that Unum can’t even get it’s facts straight by what has been previously submitted to the record.

I have no doubt but that Unum is paying some pretty hefty legal bills judging on the number of people I’ve spoken to lately who will be suing the company. No insurance company can get as bad as Unum without some blow back from insureds and claimants who one day may decide, “I’ve had enough.”

Any employer or individual who continues to buy insurance products from Unum hasn’t done their due diligence. The Internet is full of Unum disaster stories.

Unfortunately, I can’t give Unum good reports on the Blog because, truthfully, Unum Group is the worst insurance company in the world. Unum causes as much confusion in the United Kingdom as it does here in the United States. Although most citizens want Unum gone from the UK, Parliament has so far supported Unum’s efforts to remove Brits from the welfare system in favor of private disability. I wonder who is going to profit from that?

There are also reports indicating that Unum’s IMEs are conducted by physicians who are often rude and act as though they know what they are going to write even before they conduct the examinations.

There is no doubt in my mind but that Unum’s IME Network physicians are well-chosen for their overwhelming favorable reports for Unum’s profitability.

Unum’s internal medical reviews are grossly unfair and it’s denial letters contain a great deal of horse you-know-what.

It’s sad that so many insureds and claimants continue to be harmed by this company that will never be truthful, or give its customers a fair shake. There is nothing good to report about Unum Group.

 

 

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Ten years ago Berkshire/Guardian was a well-respected provider of professional disability insurance and ranked number “2” in the disability market second only to Northwestern Mutual.

Over the years, however, something happened to Guardian’s philosophy that now makes one wonder if ANY amount of information is sufficient to pay claims. Obvious from a consultant’s point of view, is the fact that Guardian’s claim review process switched from “investigation to pay” to “investigation to deny.”

While no one challenges the right of any disability insurer to fully investigate claims, there is a point of investigation that exceeds contractual necessity in order to pay claims. As with all disability insurers what is important is not what they SAY about themselves, but what they actually DO.

Although Guardian engages in commonly accepted investigative strategies such as surveillance, medical records reviews etc., the company appears to over exaggerate its investigations – not to determine whether or not the insured has a payable claim, but to identify each insured’s individual motive and intent for filing a claim in the first place.

A good example is a Guardian insured, Mr. C., who has been receiving benefits from Guardian for several years for mental health issues. In the last year, Guardian retained two “forensic” psychologists (one, an IME Ph.D.), to determine whether Mr. C. was in their words, “malingering”, “somaticizing”, and “exaggerating” for secondary gain.

Although Mr. C.’s psychologist and therapist both certify his permanent disability, Guardian asked a very prominent ex-Unum “claim-killer”, forensic psychologist to review his records 10 times in 2 months.

Then, Guardian requested an IME, again with a forensic psychologist who quoted the first doctor for 4 pages in her report. Had Guardian really wanted a second opinion, it should not have provided the IME doctor with the first “forensic” report, nor should the IME doc have relied on the first opinion in her report.

Using “forensic” psychologists to evaluate disability claims raises the bar from normal and customary investigation to criminal investigation of motive and intent, mostly for malingering and secondary gain.

It has always been my opinion that it should be the insured’s right to attend “forensic” investigations (IMEs) with an attorney who can protect their rights. Although I doubt whether any forensic psychologist would allow that to happen, it would clearly be in the insured’s best interest to ask.

Guardian also has a very annoying review practice of evaluating total disability claims for “residual disability” from the very beginning. One Guardian claims rep told me, “just in case your client is able to go back to work in the future.”

The company also takes great time and effort to seek out other passive income such as rents, royalties, monies received from serving on boards of directors, to determine if there are “earnings.” Guardian doesn’t really accept the notion that “passive income” isn’t earnings even to the point of attempting to calculate “negative income” using the residual disability formula in the contract policy. It gets pretty insane!

As I indicated previously, Guardian is not the same company it used to be and its demands for information prior to paying legitimate claims is excessive. Although I don’t use the word “sneaky” very often, it certainly applies to Guardian’s attempts to personally interview former employers, professionals who purchased insureds’ businesses, and former peers.

These types of investigations are deliberate, designed strategies to destroy reputations and credibility rather than evaluate claims. I’ve always been of the opinion that there is only one reason for insurers to interview “ex-spouses”, and Guardian takes advantage of the fact that the spouse is an “ex” for a reason.

Those who continue to purchase Berkshire/Guardian disability products should be aware of the “lion’s share” of investigation that will take place when filing claims.

It’s not only “over the top”, it’s WAY over the top. You won’t believe what you will have to put up with in order to get your claim paid.

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Bad dudesDCS is receiving multiple calls and emails regarding Unum’s voluminous claim denials. Although most private insurers engage in “profiteering” tactics to some degree, I have not received any calls from insureds or claimants regarding sudden, unfair claim denials for 2016 from any other company.

Unum has been targeting and preparing claims for denial since the beginning of 3rd Qtr., and now within 3 weeks of year-end Unum has pulled out all of its bad faith practices to eliminate claims.

A good clue to Unum’s unfair “target-denial scheme” is the placement of Reservation of Rights status on claims just prior to profitability reporting periods. DCS is receiving more calls and inquires about ROR status and what it means to them.

In reality, ROR status is suspected of being connected to Unum’s BAS payment system. When coded, claim financial reserve is reduced thereby creating an immediate financial reserve gain and contribution to profitability.

Although Unum emphatically denies any connection between financial reserves and ROR status, the placement of increasing amounts of claims on ROR just prior to profitability reporting indicates the  opposite. If ROR is NOT connected to BAS, then why bother with Reservation of Rights at all?

Unum’s counter arguments about ROR are simply not believable as indicated by increasing numbers of claims placed on ROR status at this time of year. More and more calls are coming in about Unum’s ROR status at a time when no other insurer is doing so.

It’s important to understand that deliberately targeting legitimate, payable claims for denial can be referred to as racketeering, particularly when it wouldn’t be hard to prove Unum’s “patterns of practice” to sell disability policies and Plans it has no intention of paying.

Further, Unum’s persistent violation of the multi-state settlement agreement along with state departments of insurance who turn blind eyes toward the company’s unfair violations of insurance law further disclose an extremely corrupt insurance industry against those who are most vulnerable in our society – the disabled.

We should also not forget that Unum deliberately harms thousands of middle class families who depend on disability Plans provided to them by their employers. For some, employer-provided group STD/LTD is the only affordable coverage for disability available.

Although I’ve mentioned this in many blog posts, it is so important to avoid denials in the first place rather than have to appeal and retain attorneys who walk away with most of the money. While consultants are not always successful, listening to the experts who know is also extremely important.

Clearly, given the numbers of calls and emails I’ve received, Unum is harming many people who won’t be having Christmas this year.

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