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Don’t expect your disability claim to continue to be paid if you stop going to a doctor on a regular basis. Receiving benefits is often contractually contingent on remaining in treatment with a physician who is qualified to treat you for your claimed disability.

Surgeons, for example, are infamous for not permanently supporting disability with the statement, “there’s nothing more I can do for you.” Even so, if you are receiving disability benefits you must provide “proof of claim” of “regular and appropriate” treatment. Proof of regular care is provided via medical patient notes which is why so many insurers are so anxious to request them.

Insureds are recommended to continue with consultations so that documentation can be provided as “proof” that you remain in regular care.

“Appropriate care” speaks to the credentials of physicians you are treating with. Depression and FMS should not be treated by a family physician but a Rheumatologist.

Insurance companies are aggressively ceasing benefits for insureds who have “dropped out of regular care.” Even if your specialist tells you, “there is nothing more I can do for you”, the contractual regular and appropriate care requirement must still be met.

Don’t lose your benefits because you stopped going to a doctor for regular consultations.

 

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.

 

 

 

 

 

 

Colette of Moultrie, GA on
I established Unum Insurance through my employer in 2008-2011 and the both of them are very unethical. I enrolled in short-term disability insurance as well as long-term disability insurance paying into the program for numerous of years and suffered an injury that I still have until this day. I was injured at work and this company gave me the run around about my insurance until the day I was wrongfully terminated. I asked for reimbursement and they refused. They are deceitful and in the business of making money off their consumers.
(I wonder whether this claimant understood that Unum’s STD Plans do not pay for work injury covered by Worker’s Compensation. While I’m sure that Unum does not function fairly or works to PAY claims rather than deny, STD is generally not paid to employees injured at work. In fact, Unum has been handing off other disabilities as Worker’s Comp when in fact the disabilities aren’t work injuries at all! Inside information provided confirms that Unum’s STD reviews are slanted for the purpose of denying most of them.)
Bethany of Southside, AL on
They have every reason under the Sun to not pay my claim, I have received the run around. They are heartless. They do not want to pay no matter what. My surgeon and my PCP sent in all documentation to support my absence for a month, with it being an emergency surgery. No preexisting condition or anything that my policy wouldn’t cover and Unum still keeps coming up with ridiculous reasons not to pay when it’s obvious I could not work which was most certainly clear. No food on the table, had every reason to receive money from a company I have paid into every week. They do not care.
(This post really says it all doesn’t it? Unum has a very poor public reputation in both the US and Great Britain. Middle class ERISA employees have less than a 50% chance of having a Unum paid claim. The bare truth is, Unum STD/LTD coverage does not provide employees with any kind of financial security and should not be depended on long-term.)
Michael of Somersworth, NH on
Unum yet again has wrongfully deprived another sick/injured person of their disability insurance. I have 3 specialist physicians ALL stating my need for disability and yet Unum has wrongfully denied this based on their part-time primary care doctors evaluation. On top of this, there have been 3 employees including a supervisor and contracted physician that have blatantly lied (on a recorded line) about physicians letters claiming my ability to return to work when in fact none exist. The contracted physician created a written statement claiming that one of my specialist physicians stated that “pt is ready to return to occupation at full-time.” This never happened and infuriated my physician so much that he wrote a strongly worded letter back to Unum and the contracted physician correcting their lies. In my opinion, never trust anything an Unum employee tells you and NEVER pay for any services that Unum has to offer.
(I don’t know how many times I’ve written on the Blog that Unum doesn’t tell the truth. Yet, insureds seem to want to believe what they are told by the claims handlers. The truth is, Unum reps (and their Directors) misrepresent medical records for the purpose of denying more claims. And, it does make treating physicians furious. The problem is that Unum doesn’t care that the physician “wrote a rebuttal letter”; once the company has its mind make up it rarely changes even when they are clearly wrong. Employers need to do their homework and research Unum’s payment history for group STD/LTD. Once they do, most employers should refuse to do business with Unum unless they have a full service agreement guaranteeing certain levels of payment and customer service.)
Marie of Winston-Salem, NC on
My doctor put me off work for 3 weeks because of heart palpitations and the stress of my job. I was also put on blood pressure medication but we could not get it down. The claims expert informed me that I was not sick enough to stay off work. I asked him, “should I have ignored my doctor’s request and gone to work?” He could not answer, but he did say that everyone gets stressed at work, but it should not have kept me off work. REALLY!!? Why am I paying into this plan?!! THIS IS CRAZY! I was waiting on this money to pay my bills. REALLY!??
(This is a very common Unum complaint. There are two things Unum never accepts as cause for disability: 1) stress and 2) inability to drive. Unum’s internal policy regarding stress is that “everybody has work stress” and it isn’t a cause for disability. Also, Unum discounts reports of inability to drive except for “blindness”. This claims handler overstepped his boundary since it’s not up to Unum’s reps to to say someone can or cannot work. Unum’s reps are making more and more value judgments these days and that’s why DCS, Inc. recommends communications in writing only.)

Insureds diagnosed with FMS or CFS may have more difficulty finding Rheumatologists who are willing to sign off on private disability. Although Rheumatologists continue to treat and receive payments from FMS patients, they are less likely to support FMS as a legitimate cause for permanent disability.

What I see emerging are Rheumatologists who throw their patients under the bus when it comes to signing disability forms giving patients less than sedentary capacity for work. From my perspective, about half of practicing Rheumatologists do not believe FMS or CFS is cause for disability with the remainder still willing to treat, but not certify as disabled.

I have no problem with physicians who are up front with patients about their assessments of FMS and work capacity. Some Rheumatologists rightfully discuss the fact that he or she believes a patient can “do something.” Of course, insurance companies are ecstatic when treating physicians complete forms noting, “patient is capable of sedentary work.”

ERISA Certificate holders are most hurt  by “iffy” Rheumatologists because of the “any occupation investigation” that takes place after 24 months. All insurers need to deny claims is a statement from treating physicians that patients have “sedentary capacity” since there are always “alternative sedentary gainful occupations” identified, (not always legitimately), to deny claims.

However, I do have a problem with Rheumatologists who accept fees from FMS patients receiving private disability but never inform them they won’t support total disability  or if they do, for very long.

A good example is Stephanie, who was treating with her Rheumatologist since 2003 when he retired. In the past, he supported her disability due to FMS, but unfortunately she had to find another doctor who would also support her disability.

Without informing her, the new Rheumatologist accepted a call from Unum’s doc and said, “I can’t believe this patient can’t do something.” Without any further investigation, Unum denied Stephanie’s claim. To begin, Stephanie should have discussed the possibility of doc-to-doc calls with her physician in advance, and secondly she should have been informed by her doctor he felt she could work.

It is more appropriate for FMS treating physicians to “work toward” building work capacity and engaging in “work hardening” programs and treatment plans rather than giving work capacity to an insurance doctor out of the blue. This Rheumatologist did not act in the best interests of his patient.

A situation like this should never occur. Those who are disabled due to FMS and CFS have a hard enough time supporting private disability claims without getting the double whammy of doc-to-doc calls and treating physicians who suddenly throw them under the train.

The private disability industry hasn’t changed just because FMS and CFS aren’t the nasty Internet priority anymore. Insurers are reluctant to pay FMS claims and aggressively risk manage them until they can be denied.

I urge FMS insureds and claimants to have conversations with their Rheumatologists to discuss several very important things:

  1. Whether or not you will allow your Rheumatologist to speak with any insurance company on the phone; and
  2. What your realistic work capacity is, and whether or not your physician is willing to support total disability. If so, there should be a treatment plan in place that accurately reflects the Rheumatologist’s assessment of future work capacity.

FMS and CFS are very difficult impairments to support long-term. Therefore, it is even more important to speak candidly with your treating physicians about your work capacity.

It’s not really a good thing to suddenly get a denial letter because your Rheumatologist spoke with an insurance doctor on the phone and threw you under the bus without you knowing about it in advance. Yet, this seems to happen quite a bit with Rheumatologists treating patients for FMS.

 

 

Although you won’t find many attorneys publicizing their stats, DCS, Inc. does so on a regular basis. I am always happy to share the successes DCS, Inc. has in managing private disability claims.

Currently, there are 970,441 reads on Lindanee’s Blog and I’m  very excited since it looks like the Blog will go over 1M by the end of the year. The Blog is a great success and provides disability claim insurance to those who manage their disability claims on their own.

Readership consists of claimants, insureds, attorneys, insurance companies and their outsourced facilities, treating physicians, British Unum insureds, and other medical healthcare providers, insurance “snoop” investigators (potential hackers), insurance claims handlers, state insurance departments and many others. I have a wide readership from not only those who need information to manage claims, but those professionals such as attorneys, who are looking for information they don’t have.

Lindanee’s Blog offers 1,682 article posts in 120 categories. The Blog receives from 350-800 reads per day, the highest being 970 in one day. The Blog has 208 subscribed followers. Clients continue to receive a monthly newsletter containing private information not otherwise published on the Blog.

My consulting practice continually shows a 98% success rate increasing on occasion to 99% overall. This breaks down to 100% success for initial applications. Currently, I have 101 clients who are receiving benefits on a regular basis. These clients receive assistance for requested updates, form completion, administrative services and consulting advice.

Since January 10 clients chose to resolve their claims through settlement using expert attorneys I referred them to. DCS, Inc. assists clients with over 20M in financial reserve. We continue to charge a yearly fixed fee, and do not engage in expensive back/forward fee structures that are particularly costly to the ERISA folks.

DCS, Inc. is a proactive and pre-emptive company. Insureds and claimants generally want to continue to receive benefits, and DCS, Inc.’s objectives are to assist clients with claim management to do exactly that. Although there can never be a guarantee of benefit approval, DCS, Inc. relies on my expert claim field experience to provide much-needed knowledgeable assistance.

It doesn’t make much sense to wait until your insurance company denies your claim before seeking assistance, this time from an attorney charging back/and forward fees. Once claims are denied it is far too late to avoid the expensive process of litigation that may take years.

Overall, DCS, Inc. and Lindanee’s Blog is a highly successful company for the benefit of insureds and claimants with private disability insurance. Our statistics indicating a 98% success rate clearly marks the difference between a claims expert and waiting for claims to be denied.

July 2017 was a very successful month. Please feel free to give me a call if you wish more information concerning DCS, Inc. and services offered to insureds. The company is doing very well.


Comment Note:

The most common impairments managed by DCS, Inc. include failed back/neck surgery, chronic back pain, chronic pain, cognitive and mental vs. physical issues. FMS/CFS, POTS, RSD, MS and HIV. Therefore, DCS, Inc. statistics are not derived from ” easy terminal” claims such as cancer or Stage IV cardiac issues.

It takes some expertise to manage the types of claims accepted in my client block.

 

 

DCS has been getting many inquiries concerning the letters Lucens is sending out asking claimants to sign Authorizations to obtain SSDI financial information. These requests are making some claimants very anxious. Therefore, I want to be very clear about what claimants’ rights are under the provisions of their Plans and policies.

To my knowledge no where in any of Unum’s ERISA Plans does it require claimant’s to release SSDI information. This includes any part of the SSDI file whether it is medical or financial. Claimant’s may choose to keep their SSDI file private and choose not to release any part of it.

Recently, Unum has joined forces with a company called Lucens to obtain financial SSDI information presumably for the purpose of recalculating offsets to identify large overpayments that are owed back to the company. Periodically, Unum begins these “financial recalculations” as a company wide initiative to reduce benefits to $0 to recover alleged overpayments that do not exist.

I am assuming that while Lucens is requesting SSDI files from the ERISA folks, IDI handlers are requesting extensive previously tax returns from those insureds who worked residually. Insureds who have been residually employed are at risk most, since a nefarious re-calculation of PMI (Prior Monthly Income) by Unum (or Lucens) could allege 6-figure overpayments.

But, to be clear, neither claimants nor insureds are required to sign Authorizations releasing any information to Lucens or Unum. Individuals can respond to the Lucens letters by faxing a response informing them you do not wish to sign the Authorization or release any information.

Having said this, Unum IS entitled to have a copy of the original SSDI approval letter that is quite informational and contains all of the information Unum needs to calculate overpayments, attorney’s fees, and initial benefit amounts. Unum’s ERISA Plans do not offset COLA amounts.

End of the year 1099’s from SSA do not break out COLA amounts paid from total payments, therefore I’m wondering  for what purpose Lucens wants to see SSA 1099’s. They would be better off referring to initial approval letters that have the needed information.

I suspect Unum is also concerned about SSDI increases due to additional earnings, or worker’s compensation adjustments. Calculations of benefits paid (using new methods) can produce any result. Years later, Unum calculates again and still finds additional overpayment. It’s a never-ending process to avoid paying benefits due.

Generally accepted accounting principles include a “Continuity” requirement that ensures consistency in calculation and methodology in the financial records. For Unum to recalculate benefits and offsets every few years for the same claimants and insureds is a violation of “Continuity and Consistency” in financial reporting.

Asking yourself why Unum is engaging in this focus initiative? To find money….to bolster its profitability, reduce monthly benefit payments to $0 and improve its cash flow. The money trail is always a good indication of why Unum engages in any new focus project.

 

 

 

Friday Q & A

Employee Resignations?

Quite a few questions have been received by DCS, Inc. again inquiring about resignations. There is a very popular post on Lindanee’s Blog having to do with resignations – “Resignations –  A Disability No-No. Please use the search tool from the Home Page to find it.

In short, employees should never “resign” when leaving work for disability reasons. “Resigning” means “I quit.” Employees who are recommended by their physicians to stop working go out on medical leave, they don’t quit. There is a difference. For details please read my prior article as mentioned above.

What does it mean when my Unum rep changes so often?

For Unum frequent changes in claims handlers is normal and means that as a company Unum has a retention problem, although the tendency to frequently fire people causes part of the problem. Claims handlers are assigned anywhere from 150-250 claims as a “block of claims” and when they leave those claims must be assigned to someone else.

Most often at Unum, the new claims handler begins to manage newly assigned claims in different directions causing havoc and confusion on the part of claimants and insureds. Some new claims handlers are highly critical of the way the “terminated rep” managed the claims and suddenly claimants are hit with a barrage of new requests.

Not retaining experienced, qualified employees, and/or frequently firing them, always has been a part of Unum’s continuity problem. Please note, new claims handlers may appear on files when it is decided claims should be sent to the Extended Duration Unit. (EDU) Although this. used to be a good sign to insureds, today EDU claims are risk managed even when SSDI has been awarded.

In addition to the above, Unum insureds and claimants should be aware that Unum plays musical chairs with their employees making it very difficult to have one claims handler for the duration of the claim.

How do I ask my doctor for an extension of my STD?

Well….you don’t.

DCS, Inc. recommends that patients on disability provide their physicians with a copy of their job descriptions. Office visits should include discussions about what material and substantial duties (job tasks) you are unable to do. Physicians aren’t mind readers and disability is ALWAYS work related, even LTD.

When you talk about your job descriptions and what you can and can’t do, physicians usually come to their own conclusions as to whether STD should be extended or not. Keeping treating physicians informed of what you are physically or mentally able to do keeps everyone on the same page regarding validation of disability to the insurance company,

Talking openly with treating physicians about what you are realistically able to do, or not do may also prompt your physician to examine you more carefully. Always make sure your official job description is located in your patient file so the physician can refer to it at any time. Disabled patients should always keep their physicians up to date regarding functional capacity.

Unum offered me a settlement and then promptly took it back. Why?

In my opinion, Unum settlement offers are now used to open the door to extensive file investigations. In the past, asking Unum for a lump sum settlement was a safe option for any insured or claimant. However, that is no longer the case, and DCS, Inc. is no longer recommending Unum settlements as claim resolutions.

In addition, some claimants describe to me getting attorneys involved who attempt to over negotiate settlement amounts. Unum will NOT negotiate lump-sum settlements outside of court to any great extent, and will instantly withdraw offers if pushed by an aggressive attorney to up the ante.

Until the public has a better sense of what is going on in Unum’s settlement area, it’s a good idea to stay away from asking Unum for lump-sum settlements. Some time ago, I received a call from Unum’s newly terminated settlement director who informed me the financial department was being used to risk manage claims, something that wasn’t usually done.

One gentleman claimant reported to me that shortly after he asked Unum for a settlement the settlement rep requested his SSDI file through Lucens, then wanted a field visit (not required by his policy), and more recently requested an IME. Unfortunately, this claimant may lose his benefits because he asked Unum for a settlement.

This is an issue claimants and insureds need to be very careful of.

 

 

 

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