Everyone on the planet has experienced a “very bad headache.” What distinguishes “bad headaches” from “migraines” is the long list of physical symptoms that accompanies pain in the head and the frequency that they occur.

Migraines often cause severe nausea, sensitivity to sound and light, dizziness, blurred vision, auras, vertigo and many other symptoms, What my grandmother used to refer to as a “sick headache” is mild in intensity compared to what migraine sufferers go through on a regular basis.

Insurance companies have always classified migraines as “self-reported” since the severity of pain cannot be measured, only reported by those who suffer from it. Treating physicians generally request MRIs in an effort to locate any physical cause or organic brain disease, but in most instances MRIs are not helpful in locating the cause of chronic migraine headache,

Again, insurers play the “self-reported” somaticized card in limiting benefits to 24 months. Unum’s justification seems to center on the fact that “insureds can work when they aren’t having a migraine” – an argument that is easily recognizable as profusely stupid.

It is true, however, that a characteristic of migraine is the unpredictable nature of incidence since migraines can be brought on by triggers such as stress, lighting, loud sounds, disease, and pain. One of my migraine clients years ago was denied benefits when Unum conducted surveillance and alleged he failed to put on his sunglasses after leaving a MacDonald’s restaurant. Unum isn’t stupid, the company is well aware of what migraine triggers are!

What are the chances that any employer would accommodate an employee who says, “Oops, I feel a migraine coming on and have to go home?” Unum’s reach to justify migraine denials and limitations to benefits is unreasonable and probably medically unsound.

Limiting migraine claims to 24 months of benefits is also very much connected to “pain” (as discussed in the former post); and many of Unum’s reasons for denying claims is related to the “self-reported” nature of chronic pain.

Those who suffer from chronic migraine, and who have a disability claim, should make sure that treating physicians document symptoms in detail. It is not enough to list “Migraine” as the primary diagnosis without describing the specific symptoms that characterize migraine from “a bad headache”.

Physicians should always connect the dots as to why the patient is unable to work, even when not having a migraine. Fluorescent lighting, loud noises stemming from prolonged contact with the public, tension and stress, can all be unpredictable triggers for chronic migraine.

There seems to be a common theme that causes Unum to target certain occupations, and impairments such as lack of objective evidence, DSM-5 loopholes, and “self-reported” provisions in policies and Plans.

Nevertheless, I’m seeing more and more denials and benefit limitations for migraine claims. As I’ve indicated previously special attention must be given to specifically outline symptoms. Keeping journals can also be extremely helpful in documenting frequency and severity of migraine headaches.

Chronic pain severe enough to preclude individuals from working clearly meets the definition of disability in all policies, “unable to perform the material and substantial duties of your own or any other occupation.” Still, Unum and other insurers have adopted a clear prejudice toward paying claims for pain, at least for the maximum duration of claim.

However, also contained within Unum’s policies are provisions defining “self-reported”, and those impairments that can be limited to 24 months as defined in the DSM-5. The newly defined Diagnostic Manual opens the door to Unum’s abusive strategies alleging all pain is somaticized (all in your head) and is not a credible cause for permanent disability.

While it is true that “pain” is relative, meaning one person’s unbearable pain can be another person’s “normal”, it is clearly inaccurate to classify “pain” as an imagined, and exaggerated mental illness. Although the DSM-5 now supports chronic pain as “somaticized”, the symptom is no less real to those who suffer from it.

Private disability insurers have always been opposed to paying claims for chronic pain which is why insureds should never claim chronic pain as a primary diagnosis. Although it is medically supported that pain is most often derived from physical sources such as back and cervical herniation, failed back/spine surgeries, FMS, neuropathic arthritis, and migraines, physicians often report chronic pain as a cause of disability rather than a symptom of physical disease.

Pain is always an indication that something is not physically right. For example, an insured is reported to have chronic pain as a result of failed cervical fusions and/or herniation. However, if chronic pain is reported as the primary diagnosis, the claimed disability becomes somaticized, or due to mental illness and most likely will be limited to 24 months of benefits.

In this example, the primary diagnosis should be reported as cervicalgia, radiculopathy, disc herniation etc. It is important for chronic pain claims that physicians “call a thing, a thing.” The problem is that insurers, who act in their own financial self-interest, will always classify chronic pain as self-reported whenever it is referred to in the records as a primary diagnosis.

Insurers are suspicious of reports of chronic pain because there is no objective evidence that measures pain within the body. Reports of pain are “self-reported” by the patient to their treating physicians who document “pain.” In addition, those who suffer from pain manifest other symptoms such as depression and anxiety, fatigue, and other social personality disorders requiring therapy if only to assist in the daily management of chronic pain.

Behavioral therapy is just another credible target insurers use to pay benefits for 24  months.

Consider. Shelby underwent 7 failed back surgeries (real case) and suffers from chronic pain on the pain scale at level 8 – a high impairing level of pain. Her doctor lists “chronic pain” as the primary diagnosis and immediately prescribes Oxycodone. He also recommends that Shelby seek out the assistance of a therapist to help her manage the pain and occasional secondary depression. This is a recipe for disaster for the insured, but a definite profitability target for Unum.

Shelby’s primary diagnosis should be documented as Failed Back Surgery Syndrome (FBSS) M96.1 and v454, history of spinal fusion with secondary chronic pain due to physical disease. Referrals to behavioral therapists should be positioned as needed for “rehabilitative assistance in the  management of progressive physical disease manifested with chronic pain.” Can you see the difference?

Everything with insurance companies today is how you “position things.” If you and your treating physician “position” your claim with a primary diagnosis of chronic pain, expect your benefits to be limited to 24 months, or eventually denied.

Although I don’t like selling my consulting services on the Blog, (and don’t do it very often), this is definitely a claim situation where chronic pain sufferers could use an expert. In any event, chronic pain is a popular Unum target impairment for “quick hits” to profitability.

Chronic pain is a symptom of physical disease, not a diagnosis of mental exaggeration that’s “all in your head.” The physical etiology or disease is the primary diagnosis, not the symptom.




This past week DCS, Inc. received several calls from avid readers of the Blog requesting assistance. Unfortunately, after talking with them I discovered their claims had recently been denied.

One of the most frequent topics I address on Lindanee’s Blog is the need for prevention of denials rather than having to deal with the risk of an appeal after the fact. DCS, Inc. is entirely about preemptive action and prevention of denials. This is not to say that I guarantee successful claims, but it does mean that having a claims expert on board to assist, particularly someone with direct claims experience does make a difference.

Once an ERISA or IDI private disability claim is denied insureds basically have two choices: 1) do the appeal yourself, which I do not recommend, or 2) attempt to find an experienced attorney who is willing to take your case – a very expensive option.

There are many things that can be done to place medical, occupational, and financial information in Administrative Records (ERISA), or claim files (IDI) that support disability. I can’t tell you all of them here because this information is proprietary to me and DCS, Inc. and represents a total strategy that consistently produces a 98% success rate.

Please give some thought to the benefit of assistance vs. claim denial. I would like to help, but you really need to contact me before your claim is denied, not after.


Current information suggests that Unum is working with state regulators to ensure a “no contest” fall out when cognitive claims are limited to 24 months. Misuse of the Mental and Nervous Provisions always was a characteristic of Unum Life, UnumProvident, and now Unum Group, so much so that the company is obviously making sure it’s on solid ground.

There is a large spectrum of disease that can be the cause of “cognitive” impairment from mild to the most severe. Some result from physical causes such as cognitive deficit from organic brain disease, accidents or injury, and even chemotherapy. Regardless of the etiology of cognitive dysfunction,

Unum and other insurers tend to allege the impairment is “self-reported”, or mental and nervous and limit benefits to 24 months. A large percentage of Unum’s 24 month limitations are without IMEs where cognitive difficulties can be detected and diagnosed.

Resultant decisions are occasionally nothing more than the action of a claims handler who decides to allege the claim is “mental and nervous” and should only be paid for a short period of time. Such decisions make Unum’s managers happy because coding a 24  month limitation decreases the financial reserve.

Attempting to manage a ”cognitive” claim is made more frustrating when insureds and claimants are limited in their abilities to think and respond spontaneously, as well as the ability to complete questionnaires, update forms and follow-up with patient notes

Because cognitive issues are often the result of physical disease, “cognition” should be regarded by Unum as more of a symptom than a primary diagnosis. For example, a client was diagnosed with severe encephalopathy from meningitis resulting in moderate cognitive deficits. The physical cause of disability is therefore the meningitis, not cognition and the claim should be paid to age 65 not 24 months.

However, it appears Unum is hell-bent on classifying physically caused cognitive deficit as “mental and nervous” for the sole purpose of limiting its liability. Cognitive deficit, whether temporary or permanent, caused by chemotherapy is the result of breast or liver cancer, not a “mental and nervous” diagnosis.

In addition, Unum’s reviewers seem to find convent truths when reviewing cognitive claims. Those who suffer from physically caused cognitive issues are often in behavioral therapy in order to provide rehabilitation concerning daily management of activities and short cuts to increase the capability of performing daily tasks.

Even though the “therapy” is  not behavioral in nature, Unum alleges that because the insured is receiving therapy from a mental health provider, the claim is subject to the 24 month limitation. This is an abhorrent misrepresentation of the insured’s cause of disability.

This is an issue that is likely to be ongoing with Unum. My recommendation to cognitively impaired insureds is to obtain a neuropsychological evaluations with clearly recommended restrictions and limitations that explain why insureds are unable to work.

Also, a bit of warning. Some insureds mention “cognitive dysfunction” in combination with physical disease a bit too easily, thinking perhaps the addition of cognitive issues will ensure payment of the claim.

This is wrong thinking. Once “cognitive issues” are mentioned, insurers zero in on that symptom alone and may come to the conclusion that the primary diagnosis is “cognitive” and benefits should be limited. A “cognitive mention” in a disability claim should be backed up with the results of a neuropsychology evaluation, or not mentioned at all.

It’s clear though that Unum’s current issues with cognition claims, resulting in the limitation of benefits to 24 months, is likely to continue whether misrepresented or not.

If you are having problems with Unum regarding a “cognition” claim, please feel free to give me a call.


A decade ago most disability insurers paid HIV claims with little resistance or prejudice. However, with increasing  medical advances in the treatment of HIV/AIDS and the improvement of medications, HIV patients often live a  normal lifespan.

Unum, and other insurers target HIV claims, particularly those that were approved and paid a long time ago, in order to re-review medical disability consistent with newer treatments. Unum’s goal, of course, is to NOT pay HIV claims since the popular view is now that HIV/AIDS patients can return to work full-time without restrictions.

As a consultant, I developed an expertise in managing HIV/AIDS claims a long time ago when Unum’s initial targets were surgeons and other professional medical insureds. Today, Unum’s bias toward HIV claims is even more pronounced when it documents insureds with T-Cell counts of 200 can return to the work environment.

According to most medical resources a T-Cell count of 500 is accepted as a normal benchmark for those with HIV. Newer HIV drugs often produce T-Cell counts of 600-800 with no viral load in most patients. T-Cell counts of 200 and below are indicators that patients are susceptible to serious bacterial infections, but yet Unum denies claims alleging these patients are healthy enough to return to work.

It is also true that while HIV insureds have very good labs with the newer medications, they continue to experience symptoms and side-effects that preclude returning to work such as chronic diarrhea, peripheral neuropathy, cognitive deficits, fatigue, dizziness, unsteadiness etc. The physical ability to work is not entirely dependent on T-Cell counts and viral loads alone, and other symptoms should also be considered when determining physical work capacity.

HIV physicians also contribute to the problem by documenting labs with not much mention of continuing symptoms that are the real disablers in HIV disability. Therefore, it’s very important for HIV insureds to discuss residual symptoms that are difficult to manage on a day-to-day basis. Reasonably, HIV patients cannot work if they are having difficulty managing their daily activities of living, are fatigued, and are suffering from neuropathic pain.

Of course, Unum takes advantage of the possibility of higher T-Cell counts to deny HIV claims with little emphasis on residual symptoms that are more disabling than the diagnosis itself.

If you have any questions, or are having difficulties with Unum because of a HIV/AIDS claim please feel free to give me a call. Remember, Unum wouldn’t be targeting HIV claims if it were not having profitability success in doing so.

HIV claims need not be unfairly denied, but they will continue to be targeted by Unum for “quick hits.”

Since we’re coming up on 1st Qtr. results I thought I would create a new category called “Unum Targets” and talk about what is meant by “targets” and how Unum uses a target to make money. Since I’ve had several RNs contact me, I thought I would begin with that occupation.

The occupation of Registered Nurse (LPNs also) has always been an easy hit for Unum’s occupational analysis. Most RNs are participants in employer ERISA Plans which also makes it easy for Unum to “do its own thing”, twisting and interpreting “occupations” to deny claims at the change in definition after 24 months.

As with all things at Unum, “a target” usually begins with a financial reserve high enough to warrant the lion’s share of investigation, which is generally not a problem for the occupational category of Registered Nurse. Moreover, there is biased presumption at Unum that once someone earns an RN license he/she can perform every aspect of medical care from school nurse to hospital administrator.

Specialty RNs recognize this as all bunk, but Unum continues to sell the idea that RNs are multi-purpose professionals who are able to instantly transform their credentials and experience into other medical roles they aren’t qualified to perform. I think we can all agree that an ER RN, or a Pediatric ICU RN cannot instantly get a job as a school nurse or hospital administrator. Medical specialties are not a “one size fit all” occupational opportunity.

Still, Unum continues to sell the idea, particularly during any occupation investigations, that once an RN, always an RN who can work in any other nursing field, and immediately be qualified to “get other jobs.” Why would anyone suggest that a Nurse Anesthetist could work in RN patient care, or in family practice with a doctor? Or, vice versa.

Unum also gets away with this kind of strategy because state and federal regulators, who are not medically trained, are not aware of the disparity among medical nursing specialties and training. However, RNs will tell you there is a big difference between ER nursing, and providing patient care on the floor.

Unum always seems to over use the occupation of school nurse and often documents how RNs in other specialties can cross over to this career path. This isn’t true at all since a school nurse must also be trained in educational state laws, and be trained in what the restraints of caring for children in the educational system are. Medically caring for students while in school is not an easy cross over for most RNs assuming Superintendents would even hire them without additional training.

As with all things at Unum it is always the shortest profitability distance between two points. When I worked for UnumProvident some time ago now, there was always an unwritten presumption that RN claims would be denied after the any occupation investigation. Justification? The career of a Registered Nurse is overly broad and anyone who is an RN can easily transition to another medical career field. Just ask an RN how possible that really is.

It’s important to note in these new discussions of “targets” that we are really discussing unfair claims practices. Let me define what a “target” really is.

Insurance targeting involves the following: (This is my definition although I’m sure there are others.)

“The biased separation by any insurer of disability claims into categories, occupations, impairments, SSDI status, and financial reserve high values, for the planned objective of obtaining what appears to be credible documentation in support of not paying claims.”

Notice that the targeting of claims takes place first, a File Plan is then devised to outline how to go about obtaining proof that the initial identified objective of denying claims was the right decision to make. First, claims handlers set the objective to DENY, and then they provide the documentation to prove it. This is targeting in its truest form.

Registered Nurses are targeted within Unum’s internal review procedure because Unum is able to deny claims with a TSA (Transferable Skills Analysis) alleging RNs can work in medical jobs for which they have no real training.

The strategy is profitable and Unum has no reason to stop the unrealistic career transitions it uses to deny claims.







Although I don’t do this very often, it’s time for a few claims managers, Unum counsel, or some power that is, to provide mentoring to their claims handlers regarding the use of the proper Authorization when requesting psychotherapy notes.

It’s come across my desk more than it should that Unum claims handler’s are sending mental health providers Unum’s general Authorization to request patient notes. Obviously, your claims handlers haven’t read the Authorization because in the second paragraph the Auth specifically says, “except this authorization does not allow for the release of psychotherapy notes.”

Although I have given this message to Unum in the past, claims handlers still have absolutely no idea that Unum has an entirely separate Authorization to Release Psychotherapy Notes. Perhaps a Unum Lead Specialist reader of this blog could do a mentoring session to make sure claims handlers understand the difference.

As for insureds and claimants with mental health claims, please give a copy of Unum’s general Authorization to your therapists and point out the (…) in the second paragraph. There IS NO AUTHORIZATION to provide mental health records with this particular Unum Authorization and records should never be sent.

Most therapists are now refusing to provide actual psychotherapy notes anyway, but if you are a claims handler at Unum and are managing claims, please make an effort to use the right Authorization instead of trying to pass off the general Auth as permission to obtain mental health records. UNUM’S GENERAL AUTHORIZATION DOES NOT GIVE PERMISSION TO OBTAIN PSYCHOTHERAPY NOTES. 

Please tell me you are not so uninformed that you do not realize you’re using an Authorization that says, “No Auth” to obtain something “with an Auth.” It looks as though Unum claims handlers use the general “no go Auth” to deceptively obtain mental health information that in reality it has no authorization for? Unum claims handlers need to stop doing this, it makes you look like a dunce.

Therefore, Unum counsel and claims managers who are avid fans of Lindanee’s Blog, please provide some mentoring to your claims staff and inform them about using the proper Authorization to obtain mental health records. Unum’s claims handlers should probably know better anyway.

Insureds and claimants – show Unum’s general Authorization to your mental health providers pointing out the Auth actually excludes permission to release mental health records. Unfortunately, some therapists do not read the Auth either. So please point out to them that should they receive Unum’s general Authorization, records are not authorized to be sent.

Psychotherapy notes should never be released without proper authorization.


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