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Archive for the ‘Unfair Practices’ Category

Have you ever played a game of Texas hold’em when the deck has been stacked against you? If you have a private disability claim, you have sat at the table with players stacking the deck at every hand.

We now know that the claims review process is so convoluted and deliberately planned that at least 50% of those with private disability claims are denied benefits with a stacked deck.

The claims process for all insurers has been remade over and over again to perfect those strategies that are most successful in discrediting claims. Please find below the ways in which private disability insurers actually “stack the deck” against you.

Policies and ERISA Plans are flawed and unfair in the writing. It’s important not to miss this point. Before anyone actually purchases, or is eligible for group STD/LTD Group coverage, Plans and IDI policies are adverse to the general public. Private disability contains provisions such as changes in definition, mental health limitations and discretionary authority – loopholes to facilitate early terminations.

Liability decisions, present and future, are pre-determined before the claim is ever paid. Most insurance companies have an initial review process requiring claims handlers to determine “claim resolutions”, meaning how the claim will be denied in the future. Unum’s ERDs, documented for each claim within a “Primary Plan Direction” statement, dictates “next steps” in gathering documentation to legitimize the future claim denial.

In other words, insurers pre-determine the goal as denial, and then organizes the collection of documentation that creates the illusion that a denial decision is the right course of action. To this end, third-party facilities are retained to produce persuasive documentation, setting the company an arm’s length” away from medical decisions.

Those reading this post need to STOP and think about this for a moment. Whatever path your claim has been traveling on was pre-determined at the very beginning of your claim; and every action taken by insurers subsequently is to bring a “resolution” (denial) to a timely conclusion.

Even those claims paid for a long time are on a continuous path of pre-determination of what is needed to deny claims. Claims may be left in peace for a while, but whatever the “Primary Plan Direction” is, claims are manipulated and investigated toward that end.

The ultimate goal of setting Plan Directions is to allow managers to plan unit financial reserve profitability that is in line with company objectives. If managers know in advance what claims are planned to be denied, future profitability can be projected. The problem for claims handlers is that they are “pushed” to meet denial projections once planned and documented. Claims specialists who do not meet profitability goals are performance managed, placed on probation

IME Physicians are in the lingo loop. If I asked 5 insurance defense IME physicians to write reports on a fixed set of medical documentation, they would all use the same terminology and language in their reports. It’s as though they are all reading the same manual! It becomes increasingly apparent that IME physicians who’ve been in the business of IMEs for a long time learn what “lingo” to write in order to help insurers deny claims.

“Based on my review of the information provided there are no medical restrictions and limitations precluding this insured from returning to his/her sedentary occupation.” Or, “There is no objective evidence preventing this insured from returning to work full-time without restrictions.” And so on, and so on.

Unum’s old trick was to inform the IME physician of the amount of the insureds benefit. IME physicians were so indoctrinated into the process they knew immediately how important it was to write adverse reports, let’s say for benefits in excess of $4,000/month. The greater the benefit, the  more certain the outcome of the IME report would be in support of the insurer.


If disability insurance products are adversely written from the beginning, AND the outcome of claim applications are pre-determined, AND all internal and eternal reports are biased and prejudicial, AND ERISA Plans are allowed discretionary authority, how can you ever come to the conclusion that you’re sitting at a fair poker table with normal stakes?

The answer is quite simple – the deck is already stacked against you before the cards are dealt. My message in this post is to bring home the reality that there is no such thing as “fair and equitable review”, or even, “good faith and fair dealing.”

Denial and termination outcomes are dealt to you in the first hand even though you may be totally unaware that the cards are already stacked and the game is fixed.

 

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The Hartford is quickly rising to Unum Group levels of deceptive and dishonest claims management. Not only is the company denying legitimate payable claims, but employing MCN for medical reviews, over-the-top surveillance, in combination with deception and outright lying is the new “pattern of practice” breaking the backs of its claimants.

In a way, this doesn’t surprise me since The Hartford – Unum connection goes back to the old Duncanson & Holt Unum subsidiary management team who seem to use the same unfair practices learned from UnumProvident. What is recently revealed about Hartford, however, is its trend toward disinformation, or as some might say, outright lying, or deception concerning the status of claims.

While The Hartford’s claims process always was kept a “secret”, I don’t remember claims handlers making a real effort to be untruthful, going to the extent to communicate claims were approved only to deny claims several weeks later after extensive investigation results were received. Hartford’s 007 tactics of investigation are not truthful, and in my opinion, misrepresent every aspect of information submitted by claimants’ own qualified physicians.

The Hartford’s public reputation also suffers from what is aptly described as an “unfair claims process overburdened by excessive investigation.” Once a private insurer decides that every claimant is a malingerer attempting to defraud the company, the doors are opened to unfair claims practices that investigate all claims as though they were Al Capone.

Several years ago Ray Bourhis, the prominent attorney in the Hangartner case, told me, “Unum is now no better or worse than any other insurance company.” I disagree. In my opinion every other private insurer lowered their standards to Unum’s, including The Hartford. Private disability insurers are worse now than they ever were with no state regulators looking over their shoulders.

Use of third-party medical reviewers is causing a chit storm across the entire spectrum of private claim review. As a result ERISA claimants are having to suffer the fallout of extreme fraud and investigative paranoia, losing valuable benefits depended upon for financial security.

In my opinion, The Hartford is now second to Unum on the line-up of egregious disability claim review companies. Employers should use extreme caution when spending costly budget dollars on benefits employees will never see.

All insurers are expected to engage in “good faith and fair dealing” review, but unfortunately insurer profits are not derived from “fair and equitable” review. Instead, insurers are now engaging in deceptive claims practices where telling lies through misrepresentation is more profitable.

In my opinion, The Hartford is now second only to Unum Group in deceptive claims practices. The company finally reached the bottom of the egregious barrel, a reputation that is documented all over the Internet.

I would not want to pay The Hartford’s legal bills in the coming months.


DCS is a national consulting organization that provides expert claims management services to those with private insurance. I offer free initial consultation.  Please contact me about how you can become a client.

If you need assistance with your disability claim please feel free to give me a call..

If you are interested in becoming a DCS client, please feel free to visit my website at: http://www.disabilityclaimssolutions.com

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Detailed information about DCS, Inc. can also be viewed on this blog by clicking the “Consulting Services” Tab from the Lindanee’s Blog Home Page. You do not need to go through the complicated maze of disability claim management alone. I am here to help.

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Recently I was contacted by a reporter from the Baltimore Sun and gave an interview about Unum. Although I spent some time with the reporter, I knew that information I gave him would never make the paper. Unum’s long-reaching arms of protectionism usually prevent editors from exposing Unum to any great extent.

Sure enough when the article came out it contained one or two sentences about Unum’s tendency to deny claims, and that was all. But, the article did mention that Unum’s public relations department told the reporter that out of the 650,000 claims submitted to Unum each year, Unum paid 85% of them. What?

Reading such rubbish was like old home week reminding me of Unum’s ridiculous claim in 2002 when regulators were still conducting the conduct market examination that lead to the Multi-State Settlement Agreement. Back then, Unum alleged it paid 98% of claims, which was later debunked when regulators and attorneys asked for proof of the calculation.

Unum’s recent statement of paying 85% of claims should have been investigated by the Baltimore Sun reporter. Surely, he could have asked for “Proof” of how that statistic was calculated. In my opinion the allegation of paying 85% of claims is just as ridiculous as Unum’s prior statements that it paid 98%, and here’s why.

To my knowledge, nearly all disability insurers determine, and price premium based on a 60% liability payout rate (LAR). Premium for ERISA group plans and IDI polices are both underwritten assuming a 60% risk of payout. Therefore, if any insurer were to pay 85% of claims while costing out premium at 60%, doesn’t it make sense they would have lost their shirts by now?

I know this to be true since most claims managers and VPs go ballistic when unit LARs begin to exceed 60-70%. Unum’s claim VPs are well aware of the effects of pay out rates and opt to manage them at the 60% level by demanding claims handlers do their jobs better by denying more claims.

Of course, it all depends what blocks of claims are thrown into the calculation mix to distort the outcome. Years ago I was an expert in a qui tam case involving Unum and social security. It was discovered at that time that Unum included Short-Term and Maternity claims into the statistical mix – a huge distortion. STD doesn’t have any financial reserve and is usually paid for 26 weeks, and nearly all Maternity claims are paid.

Public relations offices presume most reports are deaf and dumb on the subject of disability insurance and would be more likely to accept nonsensical statements such as, “we pay 85% of claims.” In reality, garbage-in equals garbage-out and any statistics given by Unum should be validated with proof of how the figure was derived. I’m guessing everything including the cafeteria was thrown into the mix on this one.

Let me also point out that if I were a Unum investor, and the company publicized it paid 98% of claims, I’d immediately sell my stock and run for cover. Insurance companies who continuously pay claims in excess of premium costs won’t stay in business very long. The fact that Unum remains a going-concern tells me it’s not telling the truth about paying 85% of claims.

The truth is that no disability insurance company can make a profit using a 60% payout rate to cost out premium. If Unum were to actually pay those claims that should be paid, and deny those claims that should be denied, the company would not be profitable. Therefore, Unum, like all other insurers must “risk manage” claims – devising strategies to deny legitimately payable claims in order to make a profit. The denied, legitimate claims make up the difference, and remain the path to profitability.

Insurers can’t increase premium or LAR percentages because they would price themselves out of the private disability market. Insurance is a very competitive industry. Therefore, all insurers cost premium conservatively, and make up the profitability difference by denying legitimately payable claims.  Make sense?

Unum’s mantra is to put out figures of payouts that are exorbitant, and untrue. Whenever you hear of a statistic like this, you might want to request verification of how the figure was derived, particularly if you are a regulator.

In my opinion, Unum’s pants are on fire most of time, but particularly when they allege a 85% payout. That’s just crazy!

 

 

 

 

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I’ve been posting a lot lately about Unum’s new/old chaotic claims process, and although I hope my readers put stock in what I’m telling them, there seems to be no end to new information worsening the company’s reputation.

Recent reports that Unum is unable to locate policies, and is requesting proof of claim information over and over again along with sending out “template boilerplate” letters that are not relevant to individual insureds, are making Unum insureds/claimants nervous and frustrated with a company who can’t seem to do anything right.

I received a message from a prior client who settled her claim some time ago. She is currently receiving phone messages and update forms in the mail when there is no claim to update! Why are closed claims being kept on an active risk management list? Are departments not communicating with each other?

It would appear that Unum’s claims process is so corrupt and negligent right now that all Unum insureds and claimants need to sit up and pay attention. Written communications are wrong, policy copies may not be the right ones, claims of not receiving information delay payments, really dumbed down claims handlers managing claims, rude and disrespectful staff – it’s all part of a claims process that does NOT lend toward fair, objective and equitable claims review.

Insurance state law contained within the Unfair Settlement Practices Acts require all insurers to maintain claims review processes that encourage fair review and good customer service. Unum’s current chaotic state of business is not doing that. Is anyone surprised?

Requesting update forms from an insured who settled her claim months ago is substandard internal organization at multi levels. Keep an eye on Unum; the company isn’t operating efficiently and it’s getting worse.

 

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For nearly sixteen years I’ve been informing insureds and claimants with private disability policies as to the best practices of managing successful claims.

Although information on the blog represents approximately only 10% of the total knowledge required to manage claims, by far, priority one is still the recommendation NOT to speak with insurers or their reps on the phone and to request all communications in writing.

This week I received numerous calls from insureds with questions, and they all mentioned speaking with their insurance reps on the phone. They also read Lindanee’s Blog on a regular basis, so they told me, therefore, I’m sure they’ve seen the many articles I’ve already posted recommending “all communications in writing.”

One insured also mentioned using Unum’s website portal and,  his wife and son also frequently checking it. One thing is for certain, the claimant AND his wife and son are now hacked and scooped by Unum’s investigative reps. What causes insureds and claimants to continue to speak to insurance representatives when they know it’s a recipe for a denial disaster?

Insureds and claimants describe being fearful that if they don’t pick up the phone their claims will be denied. This is not true, although communication does need to take place in some form preferably in writing.

Please note: Plans and policies DO NOT REQUIRE INSUREDS TO SPEAK WITH ANY REPRESENTATIVE ON THE PHONE AS AN ERISA PLAN OR CONTRACTUAL REQUIREMENT TO GET PAID. However, managing a successful disability claim does require cooperative communication, preferably in writing only. Although I’ve written detailed articles about why written communications are better, I’ll briefly mention them again, and hope my readers are really listening to best advice!

Opiate and Narcotic Side-Effects

Those taking narcotics, opiates, or depression medication do not have the ability to “think on their feet” so to speak, and should never communicate verbally with an insurance company. Insureds taking pain medications are targets for “stacked the deck” conversations where one minute everything is OK, while a denial letter arrives the next day. Speaking with an insurance company while taking medications with side-effects is a recipe for claim disaster.

Filtered Documentation – “The He Said, She Said Phenomena”

Claims handlers are trained to pick and chose “favorable to them” phrases from conversations they are required to document. What you say is not always documented exactly how you say it. In order to keep the insurance company honest, as in all business dealings, “you need to get it in writing”. Wouldn’t you want a complete written record of all of your dealings with your insurance company?

Psychological Need To Defend One’s Claim

Insurance companies have no interest in most of the extraneous information insureds communicate to them verbally. “I wish I could go back to work, but I just can’t do it!”, or, “I am in so much pain I can’t even lift my arms”, and “I want to go back to work, the money I’m getting for disability just doesn’t cut it.” Insurance companies don’t care how you feel, or what you wish, and most reps actually know very little about disability.

It’s not necessary to attempt to defend claims as credible since no insurer is going to believe what you say anyway. Credible claims are supported medically, financially and vocationally by the appropriate resources who are qualified to document diagnosis, income, and occupational duties. Insureds who spend a great deal of time defending their claims on the phone with insurance reps usually don’t have their claims very long. This is called OVER SPEAKING your claim.

Obsession

Sometimes insureds cannot get over the compulsion to pick up the phone and reassure themselves that their claims are secure. It may surprise you to learn that calling your claims representative is considered internally as a “red flag.”  Making frequent calls to insurers may gain you nothing but the lion’s share of risk investigation.

This same rationale has insureds checking insurance company website portals several times a day. Some  insureds actually check the website portals 1-20 times or more in a week. The insurance company keeps track of how many times you go to the website. Activities such as these are stress-related compulsions that are calming, but risky to the continued payment of claims.

Chatterbox Personality

Let’s face it, some people love to talk…and talk…and talk. Having a long phone dialog with an insurance company representative isn’t going to guarantee payment of claims. This is another incidence when OVER SPEAKING claims, giving more information than any insurance company needs, could result in a swift denial. Although we can’t change who we are, those who love to talk should try to curb that urge by requesting all communications in writing and stick with that strategy.

If I had to choose the  primary reason for the denial of disability claims it would be that insureds and claimants fear 1) that if they don’t communicate “everything” their claims will be denied and 2) insurance companies who take advantage of that fact.

I guess I could give you a couple of buzz words to remind you, like “mums the word”, “Shh……”, and “Zip It!”, but I think you get the picture here. Always respond truthfully to what you are asked, do not volunteer any other information, and always request all communications in writing.

Give yourself time to think about your answers and remember: insurance companies can’t hold against you what you do NOT say.

 

 

 

 

 

 

 

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Although one could easily say that CIGNA makes extremely unfair claims divisions, it is also true that the company is negligent, chaotic, disorganized, and incapable of providing any type of reliable customer service. How would anyone recognize an egregious claims decision with all this incompetence?

A recent claim situation involved a denial that CIGNA forgot to tell anyone about since there was no official denial letter sent to the claimant. The claims handler later agreed to review information that was “omitted” and an 83-page fax was sent. Yesterday, when I tried to verify the information was received, I was on the phone for an hour with reps who had absolutely no idea what was going on in claims.

I was told the claims handler “Marina” was not in the office, and neither was Nichols, her claims manager. I was transferred to the wrong department several times, and then placed on eternal hold. One hour later, I still didn’t know whether CIGNA received my 83-page fax or not.

This is just one more impossible incident in a long line of years of experience trying to make sense of CIGNA’s gross negligence and why it is still permitted to do business. Today, I’m contacting the department of insurance with a complaint and also requesting its help to find out whether the 83-page fax was received. Maybe the DOI can raise the CIGNA dead in customer service!

Although CIGNA was fined in a 2014 Settlement Agreement the company completely ignored the directives and have continued to engage in its own foolish disorganization and prejudicial claims process. Claims handlers speak as though they are oblivious to the claims process and offer no help at all.

In addition, CIGNA is the ONLY insurer who insists on having contact by phone with treating physicians before it pays claims. Insurance doctors make phone calls to treating physicians, and if they cannot make contact on the first call, claims are immediately denied. Physicians who “call back” find their patients’ claims have already been denied.

I’ve also found that in claim situations where CIGNA overturned a denial on appeal, or agreed to pay claims, the company turns directly around and orders surveillance again, and again, hoping to re-deny the same claim. There are plenty of indications the company depends heavily on surveillance and non-responsive doc-to-doc calls to deny most of its claims.

Interestingly, CIGNA is also infamous for not signing its letters with the claims handler’s full name. If I worked for CIGNA I’d also be afraid of signing my full name to a letter that is essentially a grammatical and confused mess! Who is running CIGNA’s negligence anyway?

In my opinion, CIGNA is clearly a disability insurer that should not exist. Employers really need to be kept informed of the confusion and disorganization that surrounds a CIGNA claim. CIGNA’s group claims may be cost effective, but employers get exactly what they pay for at the expense of disabled employees.

While Unum’s mantra is to target and refuse to pay legitimate claims, CIGNA operates under a grossly negligent claims process where anyone who works there doesn’t have a clue.

Again, in my opinion state regulators need to take a second look at CIGNA’s gross negligence and do something about it.

 

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Readers have probably read many of my articles on this blog that “Prudential and The Hartford do not fall far from the Unum tree.”

This probably stems from the fact that The Hartford is filled with old Duncanson & Holt (a former subsidiary of Unum Life) executives while Prudential hired the overflow of terminated employees from Unum – not good ones mind you.

All three companies: Unum, Prudential and The Hartford appear to manage claims with like mind and engage in many of the same unfair practices. In some cases, they use the same language in their written communications and follow the same patterns of Plan and policy misrepresentation.

When I heard this morning that a Prudential claims handler actually said, “Oh, we don’t do that sort of thing here at Prudential. I used to work for Unum, and we operate very differently”.

My first thought was that the “proof is always in the pudding” so to speak. Prudential’s mantra of unfair patterns of practice is well-known to claimants who suffer through a claims review procedure that is somewhere between corrupt and well-defended deliberate negligence. In fact, in my opinion, Prudential is second in egregious claims practices after Unum Group,.

Prudential has a history of using Registered Nurses without specific specialty to review patient notes and puts forth the reviews as back-up for claim denials. Claims with considerable financial reserve deserve more than an un-specialized RN review before denying claims.

In addition, the company also insists on obtaining mental health records even when  psychologists and psychiatrists refuse to release them. Penalizing claimants for the refusal to release actual psychotherapy notes is a Prudential “pattern of practice” it has never been held accountable for.

Even when psychotherapy notes ARE disclosed Prudential’s RNs engage in some of the most egregious misrepresentation I’ve ever come across in the 25 years I’ve been working in disability claims. For example, if the therapist refuses to mention the claimant’s “affect”, or doesn’t administer “other psychological tests”, all other information contained in the patient notes favorable to the insured is tossed and not considered.

In one particularly awful Prudential review, it was cited that patient notes mentioned a “non-working boyfriend who visited and did nothing to help support the household.” It was Prudential’s opinion that housing a “worthless” boyfriend caused the claimant to do all of the work and her claim was denied.

Prudential is also known for using “shady” third-party resources to review its claimants’ records. Companies who openly profess “assisting insurers with their goals”, and who “teach” employee neuropsychologists how to test to deny claims aren’t capable of providing “independent review” although Prudential’s management continues to profess “good faith and fair dealing.”

In addition, due to the cross-over of Unum’s management to Prudential “old Unum MDs” are often paid to perform IMEs and do peer reviews. These well-known claim killer insurance defense physicians cause extreme claimant hardship by using the same old logo to provide insurance defense with the illusion of credible reports.

Finally, Prudential is also famous for its say nothing six page letters to claimants, failure to answer questions asked, alleged lost paperwork and time/date tactics to avoid paying LTD. For example, Prudential often denies STD claims within a week or two to maximum duration so that it can allege the Elimination Period for LTD was not met.

Given all of the above you can well imagine my reaction when I heard a Prudential rep’s comment that “it doesn’t do that.”  Interestingly, Unum uses the “we did nothing wrong defense” all the time. The Hartford never attempts to defend its unfair claims practices but continues to engage them anyway.

The truth is, neither Prudential, Unum nor The Hartford “walks the talk” and they continue to collude with similar unfair claims practices and communications. The  most recent example of collusion is Hartford’s requests for SSDI 1099s, copying Unum’s Lucens debacle to locate pennies of overpayment.

Are all insurance claims reps brainwashed into thinking their respective insurance companies are doing the right thing? Typically, it takes an insurance claims handler about a year to lose the INSURANCE SPEAK and think clearly again.

Most claims handlers, however, are fully aware of what they are doing despite the false honesty in their statements.

 

 

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