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Archive for the ‘Unfair Practices’ Category

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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Although Prudential isn’t mentioned a great deal on the blog it operates very similar to Unum Group in that Unum’s rejected claims management now runs the company. In fact, Prudential doesn’t fall that far from the Unum tree in unfair claims practices. Here’s why.

Prudential is infamous for its refusing to pay mental health benefits without actual psychotherapy notes. In fact, I’ve never come across a disability insurer that misrepresents patient notes as badly as Prudential.  The company uses much of the information included in patient notes against its claimants/

The truth is, Prudential’s Employer Plans do not require claimants to submit actual psychotherapy notes in order to receive mental health benefits. Although the written burden of proof is still, “unable to perform ones occupation”, Prudential absolutely refuses to pay benefits even when providers say they don’t release their notes. Not only is this an out-of-contract request, it’s punitive to hold claimants accountable for mental health providers who regard their patient notes as proprietary to them.

In addition, Prudential has two very bad habits when it comes to reviewing medical information. First, it relies upon file reviews conducted by Registered Nurses and “clinical” team reviewers that do not have specialties in the areas of certain impairments. Therefore, there are many claims denied by Prudential without the benefit of MD medical reviews.

Second, of those claims Prudential does obtain medical MD reviews for, it is obvious the company uses the “old claims killer Unum doctors” to do it. The company also relies on trumped-up outside facilities to perform IMEs that are prejudicial and biased from the beginning. If fact, it could be said that Prudential leads the “wolf pack” when it comes to stacking the documentation deck against those who legitimately should be paid benefits.

Finally, when all else fails Prudential goes for the jugular. Recently, after two submitted appeals, Prudential went hunting for financial reasons to not pay and found that it had not reduced a claimants benefit for SSDI resulting in over $58,000 in overpayment. It looked as though Prudential would have been willing to forget the overpayment if the claimant had walked away and accepted the denial. If he doesn’t accept the denial decision, he still won’t be receiving benefits for many years, if ever again.

Finally, Prudential tries to apply the “objective evidence standard” to claims when there is no such requirement in their Plans. This means claimants with mental health, chronic pain, FMS, Lyme disease etc. are required to submit lab reports and tests, MRIs etc. before getting paid. Again, although this is an out-of-contract requirement, the company gets away with denying claims, not because of what is written in the Plan, but due to its “discretionary authority” to interpret the Plan in any way it wants.

In any event, in my opinion, Prudential’s downfall is that it continues to operate as a Unum clone, and uses unqualified RN medical reviews to back up its denials. The company also uses punitive measures when all else fails.

Although I don’t often write about Prudential I regard the company as second to Unum Group in unfair claims practices.


Please don’t forget my first Ebook “Settements” is available by clicking the link at the top of Lindanee’s Home Page “Ebooks”. My Ebooks are also available from my website located at: http://www.disabilityclaimssolutions.com.

I am currently working on Book 2 “Appeals” that I think most readers would find very interesting, particularly those who choose to manage claim appeals on their own without an attorney.

A third book is also planned by year-end on the subject of “Returning To Work After Disability” that includes information about preparation of resumes with missing work history. This will be an excellent guide for those with plans to return to work in the future.

Ebooks are free to DCS, Inc. clients upon request.

If you have any suggestions of topics of general interest please let me know by email:

DCS@metrocast.net

If you would like more information about becoming a DCS, Inc. client please feel free to call me at 207-793-4593.

Thanks.

 

 

 

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It occurs to me that Unum Group is always the Village looking for its idiot.  Yesterday a claimant received a letter from Unum’s Offset Management Coordinator holding her accountable for an imaginary deadline to receive SSDI approval/denial decisions.

Unum’s rep Mr. DD said in his letter, “The national average decision time for the Social Security Administration to make a decision on an initial application is three to six months. We received notice of your proof of the Social Security Disability Application in January.”

Mr. DD goes on to threaten the claimant, “If we do not receive the information by September 5, 2017, we will begin reducing your benefit by the estimated amount indicated, resulting in a reduced Long Term Disability benefit.”

Since when does Unum arbitrarily decide when SSA should make its approval/decisions? And, how is it that the claimant will be penalized if SSA makes an error, or takes longer than the “national average” to report decisions? What if SSA requires the claimant to have an IME and takes longer than usual to make a decision? What if the claimant has to appear before an Administrative Law Judge and it takes a year to get a hearing date?

Needless to say, Unum Group is way out of line here. To begin, there is nothing in Unum’s ERISA Group Plans that gives the company the authority to hold claimants accountable for untimely SSDI decisions. Remember, Unum does NOT reimburse claimants for estimated payments taken if SSA doesn’t approve their claim for benefits. In fact, Unum recently refused to reimburse a claimant after it denied her claim and SSDI had not yet been awarded.

Therefore, any estimates taken by Unum Group are never reimbursed if SSDI doesn’t happen. If Unum’s rep, Mr. DD, is now saying that the company will be holding claimants responsible to receive SSDI awards on Unum’s timeline upon threat of removing estimates from benefits, well….in my opinion, that’s outright extortion.

Dealing with a government bureaucracy is not walking into Wal-Mart and making a purchase – it often takes time. Whatever the alleged “national averages are”, there is always the exception when the government process breaks down and future SSDI recipients are left holding the bag.

It has been recommended to this claimant that she file complaints, not only with her state, but also her federal Congressional senators.

If Unum needs money and profitability it should find other ways rather than penalizing their own claimants for a slow and often agonizing  government process.

Finally, Mr. DD should be made aware that Unum’s Plans do not have provisions that require SSDI decisions be made within certain time frames. His letter is entirely inappropriate. If he does follow through and reduce benefits with an estimate for untimely SSA decision-making, Unum can be sued, and it should be.

If you receive a letter from Unum telling you that SSA has been too slow in making a decision and it will reduce your benefit with an estimate by a certain date, file complaints and inform Unum it has no authority via the Plan to do it.

Claimants should also notify their employers of the scam Unum is attempting. Request that employers purchase their Plans elsewhere with companies that do not hold employees/claimants accountable for SSA’s untimely decisions.

Unum is acting out of line, out of Plan, and like the village idiot who is looking for a way to make the almighty buck!

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Recent news from inside Unum seems to indicate employees are given management directives to “do as much harm as you can.” Although some higher level employees are having pangs of conscience over Unum’s new “go get’em” strategies, most are content to harm insureds and claimants for a paycheck.

I don’t think I’ve ever heard of a disability insurance company that deliberately devises  outhouse strategies to “harm” insureds and claimants, but it doesn’t surprise me that Unum finally crossed that line. For years the company has been scamming its insureds by demanding repayment of imaginary overpayments suddenly turning up as a result of one re-calculation after another.

Robert C, [not his real name] was suddenly informed by Unum he owed over $250,000 because Unum made a mistake in calculation 12 years ago. Unprepared to repay such a large amount Robert probably won’t be paid a benefit for the duration of his claim. Unum eventually agreed to only collect 24 months of the new overpayments or $40,000, but Robert still won’t see a benefit for quite some time.

Of course, these focus initiatives are in addition to other unfair schemes within the claims review process such as multi-level medical reviews, rude claims handlers, and misrepresentation of information favorable to payment of claims. Recent information also suggests that management is training U-numbie newbies to presume all claims are fraudulent and investigate them as much as possible.

I think every Unum insured and claimant should stop and think about this for a moment. Not only does Unum want to deliberately do you harm,  the company teaches its employees to presuppose you are dishonest and treat you like a criminal. Your employer has definitely not done you any favors by providing you with group STD/LTD insurance you may never be able to honestly apply for, or receive.

As a former college educator and consultant I’ve tried to inform readers not to depend on disability insurance long-term. Although this is particularly true of Unum, other companies such as The Hartford, Prudential, CIGNA, Guardian and Mass Mutual have lowered their standards to meet Unum Group in the deception corner of the ring.

Disability benefits are no longer reliable as part of a financial planning portfolio. This is especially true of highly paid professionals who purchase IDI policies thinking Unum or Guardian will pay out on a $10,000-$15,000/month benefit without a fight.

What can you be thinking? Wealthy claims represent between 2-5M dollar financial reserves [contributions to profit if denied] and your claim will NEVER get off the “target” list.  Guardian and Mass Mutual are quickly following Unum’s unconscionable claims practices.

For now, in my opinion, Unum is causing its own insureds and claimants a great deal of harm. At least we now know what the big Lucens push for SSDI financial information was all about. In the last month DCS, Inc. received more than 10 calls about “fictitious overpayments” due to various Unum alleged “identification of errors.”

If Unum Group were an honest disability insurer I would report that too, however, that’s not the case. As a company Unum deliberately works against those it collects premium from. Insureds, claimants and their employers need to think about that. After all how often should you pay for the privilege of suddenly having no income because Unum alleges you owe THEM money and reduces benefits to $0?

I think it’s time for all Unum insureds and claimants to consider what’s at stake when a company deliberately investigates claims for the purpose of NOT paying, rather than paying claims.

Claimants and insureds are not without recourse in this matter. Claimants can contact their employers and let them know what Unum’s up to. Ask employers to make better choices by spending employee benefit dollars in more positive and reliable ways. Unum’s can’t stay in business long if the company can’t give away its STD/LTD Group Plans.

It’s easy for insureds – just don’t buy Unum IDI policies (if they are still selling them). If you have an old Paul Revere or Provident policy and need to file for disability, pay attention to policy provisions and force Unum to abide by the contract policy.

Obviously, Unum is out of control and thousands of claimants and insureds are at risk of losing benefits everyday. It’s own employees are calling the company out in negative ways because of its new policies of “going directly for the consumer jugular.”

In my opinion Unum Group is bad news for just about everyone.

 

 

 

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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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