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Whenever a new client comes on board with DCS I try to make inquiries as to what the insured’s physicians have been reporting. Although responses vary greatly, I can always depend on a solid, “But, my doctor already does that!” Hum….let’s take a look and see if that’s true.

There are 10 categories treating physicians should respond to for private disability. They are:

  • Diagnoses, Primary and Secondary
  • Evidence to Support
  • Frequency of Consultation
  • Treatment Compliance
  • Statement of MMI
  • Recommended and Allowed Activity
  • Statement of Behavioral Issues
  • Listing of Future Surgeries or Procedures
  • Medication Changes
  • Medical Restrictions and Limitations Precluding Work

Unfortunately, many physicians do not take the time to adequately address each one of the above ten requirements. However, when not addressed, insurers continue to harass physicians until they eventually obtain the information, or your doctor fires you, whichever comes first.

Treating physicians are in the business of “patient care” and even though they may be experienced in reporting for disability are unaware of the specifics private disability insurers require. All too often there isn’t enough time for physicians to continue to document the above at the frequency rate required by most insurers. Large physician facilities are often “patient-in, patient-out” driven and therefore disability paperwork often fails to support continuing claims.

Diagnoses, Primary and Secondary

Physicians should always include the Primary and Secondary Diagnoses for which they are treating the patient-insured including ICD-10 codes. Differentiation should be made between what is considered Primary and Secondary, but all co-morbid diagnoses treated should be documented.

Evidence to Support

Although the “objective evidence standard” is not written in most disability Plans or policies, if objective evidence exists in the form of lab tests, MRIs, CT scans, etc. it should be updated at each new report. Physicians can also include a statement that the evidence supports, and is consistent with diagnoses given.

Frequency of Consultation

Physician should always include a statement that weekly, monthly, quarterly, semi-annual or annual visits are “considered to be appropriate care given the long-standing history and treatment of the patient.” These statements must be reasonable to the diagnoses given and consistent with the “appropriate care” definitions in private disability policies.

Treatment Compliance

It is important for private insurers to know that insureds are compliant with physicians’ treatment plans. Insureds/claimants are permitted to have only conservative treatment, but whatever the physician is communicating to his/her patient as a treatment plan should be adhered to.

Statement of Maximum Medical Improvement (MMI)

There may come a point in the patient’s treatment and recovery when there is no further improvement expected, referred to as MMI. Treating physician’s should indicate whether the insured either is, or is not, at MMI and describe what needs to take place for maximum improvement.

Recommended and Allowed Activity

Nearly every medical treatment plan includes some level of recommended non-exacerbating activity such as walking or remaining active at tolerated levels. Physicians should specifically describe what the recommended activity is.

Statement of Behavioral Issues

While it is not uncommon for disabled persons to also seek out counseling and therapy, it is extremely important for physicians to separate “Clinical Depression and Anxiety” from “Depression due to physical causes.” Or, “There are no behavioral issues associated with this patient.” In most instances any behavioral issues are secondary to physical disease and physicians should say so when patients are in therapy as a secondary diagnosis.

Listing of Future Surgeries or Procedures

This statement can be combined with statements of MMI, in that since patients have scheduled future surgery they are not yet at MMI. However, all expected future procedures should be fully documented including frequency of epidural injections, and non-surgical continuations of physical therapy.

Medication Changes

Medication or dosage changes should be documented along with side-effects experienced by the patient that lead to reduced dosages or eliminations of the medication itself. Side-effects are usually undocumented, which is a mistake for private disability purposes.

Medical Restrictions and Limitations

This by far is the most important part of any treating physician’s medical update. “Restrictions” are physical or mental activities patients may NEVER DO, while “Limitations” are those activities that can still be performed, but only to a limited extent. Without medical R&Ls there can be no disability claim. Statements such as, “Patient may not work”, or, “Patient is totally disabled”, are NOT R&Ls and no insurer will accept disability on that basis, or at least, not for very long. The dots must be connected between disability and inability to work.

It is in this category that physicians often fall short.


I’ve only given a brief explanation of each of the 10 above categories but if your treating physicians are not including this information in detail relevant to your claim, chances are your insurers are not satisfied and will keep investigating, hence frequent requests to doctor’s offices to obtain additional information.

Although there is much more to each of the above categories, I think you get the picture. Physician “letters” to insurers are NOT always considered as credible evidence of claim since most of the above information, as I’ve described it, is not contained in physician letters to any great extent, particularly R&Ls.

Patient notes are preferred by insurers to “form completion” simply because patient notes can be misrepresented, interpreted, and used to support work capacity. However, in all fairness, patient notes ARE the best supportive “proofs” of “Regular and Appropriate Care.”

The bottom line here is that some physicians do not always take the time to provide all of the above information every time an insurer update is requested. It’s important for insureds/claimants to make sure doctors keep on top of medical reporting and to seek assistance if that’s not happening.

Remember, it isn’t your treating physicians’ responsibility to manage your disability medical reporting although most physicians really try very hard to do the right thing.


Consulting ServicesDCS 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 and medical reporting 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

  • Telephone: (207) 793-4593
  • Fax: (207) 274-2331

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

 

 

 

 

In my opinion, the issue of managing mental and nervous private disability claims is rarely discussed, due in part to the sensitivity of the impairment in general. However, M&N claims have characteristics that are unique and, therefore, insurer opportunities to abuse the process are emerging at an alarming speed.

With Unum leading the sword-driven charge of insurers to use claims practices long determined to be unfair, M&N insureds are divided into two groups: 1) insureds who have primary diagnoses of mental issues and legitimately should be paid under the M&N provisions of their Plans and policies, and 2) insureds who are victims of impairment misrepresentation of physical illness in order to lessen insurers’ potential liability to age 65 or lifetime benefits.

In 2004, the California Multi-State Settlement prohibited Unum from “backdating” Mental and Nervous findings in order to deny or challenge current claims. For example, suppose Unum paid a FMS claim for four years (under the physical provision of the policy), but then currently stated there was “second look” evidence proving the claim was “self-reported”, and should have been an M&N claim all the way back to the date of disability with only 24 months of benefits. Claim denied.

According to the CA Multi-State Settlement, this practice was prohibited. However, last week I read a Unum letter to a client “backdating” mental illness in order to deny the claim currently as 24 months of benefits had already been paid. Although any insurer can “change their opinion” during the course of a claim, the proper procedure would be to pay the claim for 24 months moving forward from the date of the letter informing insureds of the change in opinion, giving insureds an opportunity to challenge the new M&N status. Unum doesn’t do that; it backdates the 24 months of benefits so that it can deny the claim now. (Or, whenever it needs the hits to profitability.)

Mental and nervous insureds/claimants are also abused in that there are constant reminders and requests for actual psychotherapy notes even when therapists refuse to release them. No Plan or policy requires the release of actual psychotherapy notes as “proof of claim”, and certainly, therapists have the right to refuse the release of proprietary note-taking if they wish. Mental health providers have finally caught up with insurers’ misuse and misinterpretation of therapy notes and most refuse to release them.

Unum’s reps send out general Authorizations to therapists requesting psychotherapy notes even when the Authorization itself says, “this does not include psychotherapy notes…” There are multiple requests for information, followed by harassment in the form   of phone calls, questionnaires, and of course, surveillance. Those suffering from mental health issues DO NOT BENEFIT from such tactics and, in fact, symptoms are worsened often to the point of suicidal ideation. Still, insurers do not let up.

Prudential persists with requests for psychotherapy notes while other insurers opt for the more expensive neuropsychological tests it can also distort and misrepresent. In other words, there does not seem to be a period of “peace” when M&N insureds can go to counseling and implement treatment plans without being harassed by their disability insurers. Insureds are expected to maintain prescribed medication levels and counseling while at the same time insurers are back-peddling harassment with paperwork and threats to deny claims. How is any M&N insured expected to improve and return to work? It doesn’t make sense.

M&N psychotherapy notes are very important to insurers because they can very easily be misinterpreted. For example, Prudential mentioned in one of its denial letters that a claimant’s therapy notes documented “her live-in boyfriend wasn’t working and not contributing to the care of her children.” Another therapist wrote, “Sharon (not her real name), reported “feeling better” and was finally able to visit her mother several hours away.” In both instances, claims were denied, unfairly mind you, but actually cited the above in the denial letters.

One M&N claimant was surveilled and was, according to Unum, “having sex in the backseat of his car with a girlfriend.” His claim was denied too!

Unum and other insurers have always abused the M&N provisions in Plans and policies using “self-reported” provisions also cited in the newer CXC LTD Plans. This isn’t something new, although CA state regulators identified M&N abuses in its Multi-State Settlement Agreement and Unum agreed not to continue the practices. Famous last words!

Just this week I contacted the Maine Department of Insurance and asked whether Unum Group was still subject to the Multi-State Settlement Agreement. I was told, “Yes they are.” The problem is, no one’s watching.

What better group of claims to abuse than Mental and Nervous when it is likely claimants are already nervous, stressed, have cognition problems, having panic attacks, not sleeping, are frequently tearful, and are unable to manage their every day lives? Harassing M&N claimants, it seems to me, is an affront to mental illness and it should be stopped.

Managing mental and nervous private disability claims is overwhelming, deliberate and an abuse of the M&N provisions in most policies. It requires insureds to be expert managers and overseers at a time when they are not mentally ready to cope with harassment and a fear of not being able to pay their bills.

 

 

 

Credible sources continue to report that Unum/Lucens continues to hunt down every nickel and dime associated with SSDI and other monthly earnings offsets including Retirement Income. The process is somewhat convoluted since Unum never proves what is owed, and asks for the same amount of overpayment from every claimant.

The process begins with a request from Lucens, Unum’s third-party paper chaser of SSDI Authorizations, and ends with a overpayment of $696, the same for everyone regardless of the disclosed actual amount alleged to be owed. Although DCS does not recommend signing any SSDI file Authorizations, Unum still requests SSDI 1099s which are recommended to provide to Unum.

Nevertheless, it appears Unum is targeting claims paid for a long-time in hopes of coming up with overpayments it can collect. What is Unum looking for? Increases in SSDI benefits due to additional income, miscalculations of SSDI offsets, retirement income that was never offset, workers’ compensation omissions etc. And, they are harassing claimants, even those with maximum duration and closed claims to repay amounts alleged to be due.

My beef with Unum is that it does not have the authority to arbitrarily calculate a overpayment and offset or reduce benefits to $0 without first showing calculations and proving to the claimants’ satisfaction that amounts alleged are actually due. Unum doesn’t do that. It simply calculates the overpayment and then offsets from benefits.

What is also suspicious is that regardless of Unum’s allegations of large overpayments due, the company always seems to come up with $696 due because Unum “is so gracious and forgiving of the remainder of the debt.” (Paraphrased) What? Why go through all the bother of targeting and recalculating for offsets and then only ask for $696 back?

This is actually an ingenious psychological plan on Unum’s part. Individuals I’ve spoken to in this situation say, “Oh, thank goodness, I only owe $696. I don’t mind paying that back”, or “You only pick the battles you can win, right?”  Oh boy! It seems that claimants are often all too ready to jump right in and pay the $696 alleged overpayment rather than the few thousand dollars alleged. Clever isn’t it?

Most of you know I’m a contract specialist, and I’d be willing to say that in a large number of cases, claimant recalculations of pre-disability monthly earnings, residual disability under WIB or PPL, COLA, indexing etc. might actually prove Unum owes claimants money back and not the other way around.

Of those client claims I’ve actually investigated and calculated myself I found overwhelmingly large numbers of claims where Unum’s figures for pre-disability earnings and indexing were grossly inaccurate. I doubt if you could actually find a Unum claims handler today who knows how to perform the calculations for indexing, COLA and WIB or PPL part-time earnings. Supposedly, claims reps send files to the financial department for calculations, but they cannot explain anything to claimants who call for an explanation.

Bottom line, when faced with a $696 overpayment letter, it might be helpful to claimants to do a few recalculations themselves to determine whether they’ve been paid correctly elsewhere in the policy. It might be possible that Unum owes YOU and not the other way around, even subtracting the $696 alleged due by Unum.

The process of “forgiving” alleged overpayments except for $696 for everyone is deceptive particularly when Unum never has to show calculations or prove what’s owed, and people are enticed to pay the lesser amount in lieu of what’s actually owed.

In my opinion, it’s a “nickel and dime” scheme that’s deceptive.

 

 

 

While most insureds seem to envision surveillance as a video camera sticking out of a blacked-out van across the street, it’s clear that HUB and other insurance investigators have fine-tuned the art of spying on those who receive disability  benefits. No longer is there a lone-wolf investigator hiding behind neighborhood  bushes, but a very sophisticated, planned operation that views you coming and going.

Most surveillance today is “tag” in nature meaning there are at least two or more investigators strategically positioned at various points in and around your residence and geographical location. There can be two or more cars involved to prevent insureds from noticing the surveillance. Investigators often meet at certain locations and change the cars they are driving to foil the cleverest of insureds from blowing their cover.

It would not be unusual, for example, to have two HUB investigators stationed around your house. When you leave, one HUB guy pursues you and then lets the second vehicle take over. The name of the game is to record insureds, unnoticed, and record as much activity as possible.

Attending a field interview at McDonald’s is very interesting. When you enter the parking lot, take notice of cars backed in. Who backs in their cars at McDonald’s? Only those videotaping out the front window perhaps?

Before the surveillance actually takes place, investigators have already hacked into social media and have a good sense of where you live, what cars you drive, property you own and where you go. Social media hacking isn’t just for disability, in fact, Travelers gets into Facebook pages looking for “hazards and perils” to increase automobile premiums. A picture of an insured getting into a car with a Bud in his hand could cost him more for auto insurance in the long run.

An average three-day surveillance costs from $800 to well over $2,500. I suspect use of the  more sophisticated equipment such as drones and special software is costly and isn’t used in every surveillance investigation. I am still getting word that insurance surveillance, while frequently used, is shopped for the cheapest deals in town.

I am also told that technical equipment commonly used for surveillance can record as much as 500 ft. away. While this article isn’t intended to discuss all of the equipment available for surveillance, it’s astounding to think that you can be seen, and recorded, from 5 football fields away by two or more investigators in several different cars.

Insurance surveillance isn’t nothing. Insurance companies are willing to invest millions of dollars per year in having their insureds spied upon. You can bet it’s profitable.

Like field interview requests, surveillance is an indication there are internal red flags identified that need to be resolved. Although the primary intent of surveillance is to identify “inconsistency of report”, misrepresenting what is actually recorded by translating activities into METS and work capacity goes a long way to assist insurers to deny more and mor claims.

It is summer. Fourth of July festivities are about to begin. The HUB parking lots are empty because they are working diligently to record you exceeding your restrictions and limitations.

If you have a disability claim, please consider that surveillance reflects there is a red flag associated with your claim, and you may be the victim of multiple investigators watching you, and following you at the same time.

Any risks you take in exceeding your R&Ls could result in deniable claims by Labor Day.

 

 

This morning I spoke with someone who told me that he calls Unum on the phone and speaks to the representative quite often; he does NOT have a copy of his employer’s Plan and has never read it; uses Unum’s website portal for communications which he checks at least once a day; uses Facebook to speak with his family; and doesn’t think he has anything to worry about because he doesn’t do anything wrong.

Wow. My first reaction is that the gentleman caller has a great deal of trust in an insurance company doing its best to not pay him. I realize that not everyone has access to Lindanee’s Blog, but seriously?

Although I have said this on many occasions, I probably should say it again. Insureds and claimants cannot defend what they haven’t read, or have possession of.  Insureds couldn’t even verify that policy or Plan citations in letters are accurate, or if Unum calculated the Elimination Period correctly etc. Taking any private disability insurer “on faith” is a very naive mistake.

Consider. I received several phone calls this week from those who told me, “I spoke with my Unum representative and he told me………”, which when I heard it, knew it to be wrong. Unum reps aren’t trained to adjudicate disability Plans and policies and therefore they aren’t knowledgeable enough to answer contract questions.

Yet, even after I informed the caller of the correct information, he still wanted to believe Unum. I guess  as a Consultant, there are some things I just can’t change. This particular caller was receiving $4,000/month in benefit and was risking around $500,000 in future benefit. Naïveté can be costly.

Copies of ERISA Plans should be provided at the time of annual enrollment, an ERISA requirement most employers don’t know about, or don’t want to know about. Bottom line, given the total financial reserve of private disability today it’s costly to NOT know what’s at stake and how the process works.

In addition, let me say that my client list includes claims for attorneys, plastic surgeons, scientists, engineers and others who are well-educated and credentialed. Private disability can be an equal credential spoiler.

The best educated insureds who are naive about the claims process are more likely to lose benefits because he/she believes their education makes them qualified to manage their own claims. In today’s world it is more likely than not that insureds seek additional information and assistance to ensure payment of legitimate benefits – regardless of educational backgrounds.

Finally, insureds need to understand from the beginning that private disability insurers lie to you about most things. In order to deny more and more claims, insurers continue to devise claims review strategies that misrepresent information and “position” arguments in highly covert and unfair ways.

Hiring attorneys who know less about the claims process than you do isn’t the answer either. These same lawyers may have experience in ERISA litigation but who wants to have no benefit and a claim in court? Most people just want to be paid the benefits they are entitled to without giving up 40% of future benefits. You shouldn’t have to pay expensive attorney fees to have the blind leading the blind.

Insureds/claimants should make a real effort to understand the private disability insurance claims process. It’s not going to help you to allow your insurer to manage your claim when they are “staking the deck” against you with every activity.

You have to be smarter these days and one step ahead of the monsters.

 

Friday Q & A

Can I go to Disney while on disability? Can I play golf while on SSDI? Can I go to Canada to see my family while disabled?

I’ve been doing quite a bit of talking on this subject lately. Apparently, there is quite a bit of interest in just how far insureds can stretch their medical restrictions and limitations and still get paid. Disability reporting is serious business and whatever medical restrictions and limitations reported by doctors to insurers should be adhered to, if only for your health’s sake. Reporting excessive medical restrictions for secondary gain could be interpreted as insurance fraud, evidenced by the fact that although you reported R&Ls, you’re clearly not abiding by them.

What you can do for activities depends on what your R&Ls are. If you’re telling the insurance company you are severely fatigued and cannot work, then of course you shouldn’t be playing 9 or even 18 holes of golf. If you reported chronic pain and limitations in standing, walking and sitting, then I don’t see how you could possibly walk around Disneyworld, or go on any rides. It’s possible, but prolonged standing and walking is equivalent to around 10 METS and demonstrates “sedentary to light” functional capacity, whether you can actually go back to work full-time or not.

There is a fine line between demonstrating “work capacity” and being able to return to work full-time. I get that. Still, in my opinion, anyone who can play golf, a very physical and mentally focused game, could probably work, at a minimum, a sedentary job. Whatever you are reporting to your insurance company as a restriction, is what you can’t do, and shouldn’t do.

Why are Unum claims handlers giving me inaccurate information? The reps don’t seem to know what they are talking about?

I’ve noticed the same thing, but unfortunately it’s not just Unum – all insurers now seem to be hiring the walking dead. There are quite a few claims handlers who seem to share contractual information that is inaccurate at best. What bothers me the most, however, are insureds who do not have copies, nor have they read their policies, and would never know the difference between accurate information and misrepresentation. Insurance companies can only get away with deception when insureds/claimants are not knowledgeable about the process.

It is very important for insureds to “correct the record” when reps communicate inaccurate information – something DCS helps our clients do on a regular basis.

What about these Unum Questionnaires I get all the time? Are they trying to trick me?

Recently, I was asked by a client to help him with a questionnaire received from Mutual of Omaha. As I read through the document I was taken aback by the amount of private activity information asked. Although insurers do have the right to investigate claims, insureds should know that there a line that can be drawn between “investigating claims” and excessive prying for the purpose of getting insureds to admit to work capacity without realizing it.

Insurance questionnaires are often wolves in sheep’s clothing. And, insurers are well aware that the first instinct of insureds is to fill up every empty space on the form with information – a real claims faux pas. “Less is more” when it comes to filling out Questionnaires and insureds should NEVER volunteer information not asked. All insurance inquiry forms are designed to encourage insureds to voluntary provide information about activities that can be compared to work capacity. If, by filling out the forms, you give yourself work capacity, even better for insurers – less work for them.

 

 

 

 

I received the following comment to the blog this morning. I appreciate the fact that this person took the time to care about others who are private disability victims. Here is the original text. I’ve also included my response.

COMMENT


“I work in a doctor’s office and see the results of this several times a month. It is not worth it. The videotapes aren’t just used to deny claims. Most patients spend years seeking a diagnosis and retaining a knowledgeable physician. It is becoming rare for specialists to even support disability claims or agree to fill out forms and deal with insurers. The insurer uses that and our doctor shortage to their advantage.

In addition to harassing the physician and staff, the skillfully edited tapes are always sent to your doctors. We have even seen them on patients we haven’t seen in years, to get an “opinion” on your reported symptoms. The fastest way to lose a doctor is by not following orders or having their reputation and medical opinions questioned due to your actions. Yes, doctors know you have good days but even selectively edited tapes are powerful. Suddenly, the doctor has questions at the back of his mind and you lose the only local specialist. It will also mean they pass along that information to other doctors who call when you try to retain them. Now without financial resources, there may be no good replacement, let alone one willing to deal with the hassle of a disability claim for a non compliant patient.

The insurer wins by turning your own doctor and your reports against you. Follow your doctor’s orders, honestly report, and assume you are being recorded in public. Finally, PLEASE hire someone like Linda who really knows how to help you.”

MY RESPONSE


Thank you so very much for your comments concerning surveillance and the after math of consequences that takes place. I sometimes wonder whether my readers take me seriously, or believe that many of my posts are reactionary trying to scare people into hiring me.

The truth is, all of the issues I write about on the blog are either provable by documentation, or have been personally reviewed by me, or have been directly communicated to me by credible sources, or sadly, I’ve done it myself as a former claims handler.

I appreciate your comment as I now realize I’ve never discussed what happens to surveillance CDs once they are provided to insurers. What you describe from physicians’ offices is very accurate and probably is the most common reason why physicians “fire” their disability patients. At the time, it may seem pretty benign to romp in the woods at a family picnic by the lake, until you receive a call from your doctor’s office that you need to find someone else to support your disability.

Although a few treating physicians side with their patients and respond, “The surveillance CD does not depict anything other than my treatment plan communicated to my patient and does not change my medical opinion, or medical restrictions”, physicians have a tendency to “act strange”, or “become very conservative” in reporting future R&Ls.

Doctors may not share with you that they have viewed a three-day recent surveillance from your insurance company and that he/she felt a bit of an idiot for recommending total disability. This is the point in time when you begin to notice a change in your doctor’s attitude and facial expressions during visits because in the back of his mind, he is now wondering if you can really work. Remember, “seeing is believing?” That goes for treating physicians as well.

Thanks again for your comment and support. Sometimes I do feel as though people do not always believe me when I write articles or make recommendations. Just yesterday, an insured told me she wanted to wait to hire me so she could “just wait and see what happens.” Sadly, the next thing to happen will be a denied claim when I can do nothing to help her, and her options are limited and costly. Unlike lawyers my focus is to assist insureds to “prevent” denials, not have to deal with them afterwards.

A special thank you to all of my readers and supporters. I couldn’t do this without your interest and continued support!

 

 

 

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