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The most popular views on Lindanee’s Blog are the articles concerning “Returning To Work After Disability”. Although insureds and claimants receiving LTD or disability benefits may be able to return to work in some capacity, resume preparation may be somewhat problematic especially when trying to explain “lost time” without jeopardizing jobs they are qualified to do.

Let’s face it. Returning to the workplace can be frustrating particularly if you’ve been on disability beyond the age of 50 and have “year gaps” in your work history. Those who have been on disability for years also need to position a return to work very carefully so that their interests can be protected under “Recurrent” provisions in their policies.

As a former Dean of Students and Faculty at a local college, it was very important to teach resume writing and employment skills to non-traditional students such as those training for second or third careers after raising families, or after periods of disability. Of course, just knowing how to position and prepare a return to work while still receiving disability benefits will be extremely beneficial to those who are able to return to partial or full-time work.

A resume is a prospective employer’s “first look” at your education, skills and experience and is the first step to ensuring employability in a competitive work environment. I’m often asked, “How do I explain my lack of employment for the 6 years I was on disability? What can I do to maintain my skills while I’m disabled if I want to return to work in the future?”

In order to be of further assistance to insureds and claimants, I will be offering resume preparation and return to work counseling to all DCS, Inc. clients free of charge. Those who are not currently clients can either become clients, or pay a separate fee for resume and return to work services. These services are available to those who are currently receiving private disability benefits and who would like to pursue a seamless claim transition to work in the future.

Please keep in mind I am not an employment agency and will not be able to find or guarantee employment.  Rather, my services will help insureds and claimants prepare to return to work including the preparation of a good, clear resume. The rest is up to you.

Resume preparation and return to work counseling is free to all DCS, Inc. clients. Therefore, if you are currently on claim and are thinking about returning to work in some capacity, please feel free to give me a call for more information.

DCS, Inc.  (207) 793-4593 or DCS@metrocast.net

 

FearHave you ever heard the old saying, “Those who control your money also control you?” Although one could say this applies to most occasions in life, it is particularly true of private disability claims and the extent to which insurers use FEAR to transform disabled persons into dollar sign profits.

Lately, I’ve been hearing nervous insureds saying, “I don’t want to do anything to jeopardize my claim because I need the money.” Obviously, those who are receiving benefits fully recognize the “control” insurers have over them and are willing to do anything to ensure the “checks are in the mail.” Unfortunately, doing everything the insurance company asks does not a successful paid claim make.

In fact, in my experience those who refuse to “push back” and defend their claims, Plans and policies are more likely to end up with zero benefits at the end of the month. Saying nothing, doing nothing, OVER SPEAKING claims, and providing as much information as possible is a dead ringer for denied benefits.

Fear causes people to do and say things they normally would not do. The elephant in the disability room is that insureds and claimants need and want to be paid benefits, and insurers do not want to pay them. In the end, from both perspectives, it’s all about the money.

Sometimes insureds ask me, “Should I see this specialist?”, or “Should I have this test to keep my benefits?” Putting treatment and continuously changing medical care just to keep benefits coming in is a prime example of how far insureds are willing go to ensure the money keeps coming in.

My answer to these types of questions is that those who are disabled should put their health and well-being as the first priority and let the claim fall into place after.

Disability insurance policies, ERISA in particular, are adverse to claimants from the very beginning. Plans contain 24-month changes in definition, 24 month mental and nervous limitations, offsets, self-reported and subjective provisions, appeal timelines and discretionary authority. One could easily say that insurers have claimants by the cojones from the very beginning.

Not pushing back to defend what little rights you have doesn’t mean benefits will be paid to maximum duration. In fact, those who appear a bit too willing to cooperate and are over accommodating often creates red flags that buys the lion’s share of risk management activity such as surveillance, field visits etc.

Another example is the fact that insureds and claimants continue to speak on the phone with insurance representatives thinking, “they HAVE to.” Actually, there is no disability policy I’m aware of that requires insureds to speak verbally with any disability claims handler on the phone. (Have you read your Plan or policy? It’s true.)

Yet, I still receive calls from those who say, “I just spoke with my claims handler….I told my claims handier something and now I’m in trouble….My claims handler was so rude to me…..They asked me why I don’t just go back to work…..”

Disability claims “Best Practices” is for insureds and claimants to request all communications in writing. Those who are taking prescribed pain medications, opiates, or depression drugs should NEVER speak verbally with insurance representatives anyway.

One of the best ways to “defend” ones rights under a disability Plan or policy to ask for all communications in writing so that there is never a dispute as to what is said, requested, or documented in the file.

Nevertheless, fear causes many insureds to continue to OVER SPEAK claims on the phone by giving far too much information that can be used against them in the future. A large percentage of claims are denied citing “you said…….” as the reason.

Since disability claims are adverse to begin with, it makes sense that all insureds and claimants should defend their rights under Plans or policies by “pushing back” when  claim requests are burdensome, overbearing or harassing. I’m not talking about coming across as aggressive or arrogant, but politely setting the standards as to what is appropriate claims investigation and what is not.

Challenging medical “misrepresentations”, and “snatching” medical information from patient notes favorable to insurers while ignoring all else favorable to insureds should always be challenged and corrected for the record.

Not speaking up to defend what’s right is a sure way to a claim denial. Since private insurers have you by the “kishkes” anyway, it’s always a good idea to speak up and use what clout you have to protect your benefits from unfair denial.

Giving in to every request, every unfair demand, every out of contract misrepresentation doesn’t assure anything but a swift kick in the guts from insurers  who do not want to pay you.

 

 

 

 

Friday Q & A

I’ve had many very interesting questions submitted to DCS this week. Thanks to everyone who submits questions that are most likely important to others as well. Since my readers are too fearful to provide support to each other via the comment section, I like to answer questions here as Q & A. If you have a question you’d like answered, please send me an email.

What are some of the things I need to know about Unum?

WOW! What a question. I’ll try to list a few for you here:

  •  As the renamed company of Unum Life Insurance and UNUMProvident, Unum Group has a history of unfair claims practices that can be verified by the Multi-State Settlement Agreement, Georgia Conduct Market Examination and the California Settlement Agreement.
  • Through its claims management, Unum deliberately targets specific claims and then “works” them through their internal claims review process with deliberate intent to deny at some future date.
  • Unum relies solely on internal medical reviews (including insurance defense outsourcing) as back-up for denials. Medical information submitted by insureds and claimants is omitted from consideration. The company also has a hierarchy of medical review that creates the “illusion” of credibility. Unum systematically stacks the deck against insureds by “snatching” certain key phrases in patient notes and records favorable to them, while ignoring all else in the record favorable to insureds.
  • Unum misrepresents policy Plan and contact provisions, and is often dishonest in other ways.

Although I could probably fill a book with details about Unum Group, please let me recommend that you Search the Blog for additional topics and you will find out plenty of detail.

How is appropriate care determined?

Typically, treating physicians dictate what “appropriate care” is based on their previous history of consultation and treatment with their patient insureds, although it is very rarely documented as “appropriate care” in the records. Most insurance companies accept that fact except for Unum.

On occasion I’ve seen Unum cases where it sends out threatening letters to insureds informing them that if they don’t get into certain care, claims will be denied. A good example is a claim where the insured was diagnosed with meningitis and encephalitis who now has residual symptoms of cognitive deficit. Unum threatened this insured that if he didn’t get into mental health treatment and counseling Unum would deny the claim at 24 months.

Clearly, the cause of disability was physical in nature and not subject to the 24 month mental and nervous limitation and yet Unum determined “appropriate” care to be behavioral requiring counseling therapy. DCS, Inc. assisted this insured in proving to Unum that it’s determination of “appropriate care” was inappropriate, and we were successful.

It’s important to remember that TREATING PHYSICIANS determine what is medically appropriate within the recommended guidelines of the medical community. An example of inappropriate care would be a person diagnosed with depression and anxiety being treated by a family physician; or, treatment outside the specialty of the claimed impairment.

If your physician fails to document what he/she recommends as “appropriate care” you can be sure the insurance company will, particularly Unum.

DMS is making a request for an IME. How does DMS work?

Disability Management Services, Inc. is a reinsurer who buys up blocks of business and assumes the risk of other insurance companies.

By definition, DMS isn’t really an insurance company itself, but more like a corporate holding company who buys up other businesses, put minimal money into them, and then sells them at a profit. State departments of insurance do not recognize DMS as an insurance company and complaints are usually handled with responses of, “we have no jurisdiction.”

There are only two possible outcomes for claims managed by DMS. Either the claim is paid and IME’d to death until it can be denied, or the claim is “settled”.  Again, reinsurers by definition won’t pay claims indefinitely so those insureds who think DMS will continually pay claims without problems are very mistaken.

In one year, DMS requested one of my clients submit to 5 separate IMEs that kept coming back in her favor. Finally, after two years my client agreed to a lump sum settlement in order to have some peace.

DMS will NEVER stop requesting outside evaluations until a report finally shows up in its favor. It is very important for insureds to recognize the goals and objectives of reinsurers as different from regular private disability insurers.  Claims handlers are far more aggressive as well.

Can I really sign away my ERISA rights?

This question reminds me of occasions when Unum used to send out letters asking claimants to “sign below” waiving ERISA timelines for appeal review. It would be very unwise for anyone to sign such a waiver.

It’s egregious for Unum to ask you to give your permission to waive ERISA timelines and I never recommend doing it.


ebooksPlease 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.

 

 

 

I recently had an opportunity to review a Prudential Questionnaire sent to a claimant, and to be honest I couldn’t believe the amount of hogwash the company is asking claimants to provide.

Do you use your computer? What for? Do you shop? What do you buy? Gifts? Do you sleep during the day? How long do you sleep? Do you drive? Where do you go? Do you go out with friends and relatives? How often?

Honestly, the questions go on and on attempting to encourage responses that will automatically give claimants at least sedentary work capacity, and by their own hands too!

Of course, the questions have absolutely nothing to do with material and substantial duties precluding someone from working, but have an awful lot to do with physical activity. I have to admit, though, asking, “Do you read? What do you read?”, is a bit too much for a claimant to take!

The problem here is that I’m sure Prudential claimants believe they MUST answer these types of questions in order to receive benefits. Prudential uses the fear that is already instilled in claimants to invoke controlled responses to questions they never should be asked. Fearful people often respond in ways that are adverse to themselves.

Reading Prudential’s Questionnaire reminds me that the questions are not unlike types of visual surveillance except that responses are coming from claimants themselves – a very clever move on Prudential’s part. It’s always a great deal easier to get claimants to admit they are active enough to go back to work, or, so says Prudential.

I’d like to remind claimants that the only burden of proof they have is what is written in their employer’s Plan concerning the definition of disability. One of my pet peeves is disability insurers who attempt to hold claimants to a higher standard than their Plans do.

Holding claimants accountable to the “objective evidence standard” is a very good example. Prudential’s mental and nervous reviews are infamous for alleging there is no mention of “affect” in the patient notes, or there has been no psychological testing.

Does the Plan document require that? Of course not; Prudential holds claimants to standards that do not exist in the Plan. The only standard claimants need to meet is to prove medically they are incapable of performing their material and substantial duties. Most Plans do not require an “objective evidence standard.”

With respect to Prudential’s Questionnaire, it’s obvious the company has its nose in your lap, and you don’t need to put up with that. You are allowed to diagonal line through specific questions by asking one of your own, “Please explain to me what this has to do with my Plan and the definition of disability.”

Prudential won’t explain it, because it can’t. It obviously draws no distinction between information relative to the Plan and poking their nose into your business to see if you are active enough to go back to work.

Claimants need to pay attention to all Questionnaires that are wolves in sheep’s clothing. You might want to consider responding that if it isn’t pertinent to your Plan you won’t answer questions about your private business.

That is assuming, of course, you aren’t at the same time writing all about it on your Facebook page. Caution is needed here to prevent Prudential from alleging you have work capacity because…..”you said….”

No insurer can hold against you what you do not say or write.

 

 

 

Several times a year I am asked the question, “What do I need to do to be a disability claims consultant?” The only response I can give is to describe what I did to have the qualifications to do what I do. I don’t really believe there are very many of us out there, but I’ll try to describe what I did to obtain the expertise needed to be a disability claims expert.

First, I spent nearly 10 years as a disability claims specialist, working for Unum Life Insurance and then UNUMProvident. I was trained as a contract and settlement specialist and advanced my standing by passing various insurance industry courses. The alphabet soup you see after my name are insurance credentials I earned by passing industry tests such as Health Insurance Associate (HIA), Disability Income Associate (DIA) and Disability Health Professional (DHP).

After leaving Unum I worked exclusively for the next two years for attorneys as an expert witness and gave depositions in no less than 50 cases. An expert witness must also have writing skills to provide expert opinion reports that are legible.

Next, I created my own consulting business and have supported insureds and claimants with private disability insurance. Although it is rarely mentioned I also have the knowledge and experience to assist with health and life insurance and long-term care. DCS, Inc. is now on its 15th year. So, I’ve had 25 years experience in the disability claims area.

Providing consulting assistance to individuals presumes a certain accountability and responsibility to act on behalf of the interests of those you represent. The requirements of my state are such that I had to take and pass a test to obtain a license as a Life & Health Consultant. In addition, I’m required to carry a $20,000 Bond, Additionally, I purchase liability insurance.

Prior to working at Unum as a claims specialist I was an Assistant Professor of Accounting, Accounting Department Chairman, Dean of Faculty and Vice President of Academics at a local college. My tax and accounting experience has been invaluable to me as a disability claims expert as was my ability to write and edit our college catalogs and prepare presentations to legislators.

Although my early days working in Unum’s Headquarters are rarely mentioned, for a period of two years I initiated stock purchase transactions for the top 26 Unum executives through Smith Barney.

Therefore, I suppose if someone is interested in doing what I do, a good starting point is to get a job as a claims specialist and stick with it until you learn the business, and I mean the good, the bad and the ugly.

Qualifications for a disability claims consultant is all about the experience, credentialing and licensing. Last but not least, is the ability to guide with compassion, with honesty and truthfulness, never exaggerating, nor holding back the reality of claim situations – to always act in the best interests of your clients while at the same time being firm about what the best course of action should be.

Having the experience and diversified background to advise on many different areas of claim management is also essential.

If you really want to be a consultant like me, begin your education with hands-on experience, gather the credentials and then learn the compassion it takes to understand the individuals behind the claims.

 

Friday Q & A

Can a person be denied health insurance or reimbursement for treatment of fibromyalgia and chronic fatigue?

While there are so many different versions of health insurance available the short answer to this question is that health insureds are entitled, or not entitled, to whatever the health insurance policy says they are entitled to.

I don’t think it’s unreasonable to say that most people don’t actually read their health insurance policies. However, everyone should make an effort to obtain and read their actual health insurance Plans so that there are no surprises in the future when emergencies occur. It is entirely possible that some health insurance policies may not cover FMS or CFS,  limits reimbursement for treatment, or increases co-pays.

The best pre-emptive solution to insurance problems these days, including health insurance, is to be a good consumer of insurance products by reading the policy before purchasing it and having a thorough understanding of what’s covered and what isn’t.

What is Unum’s Navilink?

Navilink is Unum’s internal diary system. In theory it is a type of SOAP NOTE diary system whereby all activities taken on a claim can be documented. However, if you actually read the Navilink entries you will see that there are quite a few blanks left in the claim program.

At one time Unum Life Insurance was a stickler for documentation. I can remember management telling the claims handlers: “If it isn’t documented in the file, it didn’t happen.” Some Unum managers actually taught their newbies that one should be able to pick  up any file and have a complete record of everything that took place in the review process.

Eventually, Unum’s management realized this kind of detailed documentation was discoverable shot Unum in the foot at the time of the Multi-State Settlement Agreement investigations, and management decided to advise claims handlers not to go over board with claim documentation.

Therefore, while Navilink seems to keep claim activities organized internally, the notes rarely assist attorneys and Plaintiffs with information of wrong doing – intentionally, of course. The same is true of Unum’s Benefit Manual that describes separate processes but does not explain how a claim is reviewed from Step 1 through resolution.

Navilink does keep track of phone calls, and basic review information but it is not the whole story of what goes on in the claims process. Just try to find details about a “roundtable presentation”, or who attended Team meetings and what the outcome was. This information is NOT documented in Navilink, nor is any other information that could be viewed adversely against the company.

While Navilink might be a good way to keep information organized internally it shouldn’t be regarded as a complete record of activities taken on claims. It isn’t.

Should I play golf when I’m receiving SSDI?

Oh boy. Here we go again.

It depends on what you and your doctors are reporting to SSA, or your disability insurer as to what your restrictions and limitations are and why you can’t work. As a disability consultant I’m of the opinion that there are very few insureds who would be able to play golf after alleging total disability, or if they were able to play golf probably have at least some work capacity.

Working is both physically and mentally healthy, and anyone who has work capacity should be working, not playing golf.

The physical activity of playing golf involves arms, legs, hands, shoulders, trunk and back, weight-bearing capacity, lifting, walking, stamina (even if you use a cart), and mental capacity to figure out all the variables (terrain, wind, slope) and recording an accurate score at the end.

I wouldn’t want to be the one to have to explain to an insurance company how I am able to play golf but can’t work because I have chronic pain, back pain, carpal tunnel, fatigue, muscle weakness, lack of physical stamina, keeping me from working. Insurance companies generally regard anyone who can play golf as having work capacity.

Several years ago there was a disability case of a semi-pro female golfer alleging FMS kept her from working and yet she played in a pro-tournament. Unum denied her claim, and probably rightfully so. Another insured claimed a Unum disability for back trouble but took a part-time job as a ski instructor. Unum denied that claim too!

Finally, CIGNA caught a claimant with chronic pain engaging in motor cross bike tournaments and denied his claim when he bragged about it on his FB page.

Whether it’s private disability or SSDI insureds should abide by the medical restrictions and limitations provided by their physicians and reported to insurers. If you can’t work due to a set of physical R&Ls chances are you can’t play golf, ski or do motor cross racing either. It’s just common sense.

 

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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