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Posts Tagged ‘disability insurers’

Q&A4 If a private disability attorney helped me to get approved for SSDI do I still have to give Unum back the overpayment?  Does Unum collect back payments? Does Unum or GENEX decide if you are approved SSDI or not?

Of course you have to give back any overpayment due. And, yes Unum collects overpayments.

Questions like this worry me somewhat because it means that claimants aren’t reading, or understanding their policies or ERISA Plans. SSDI overpayments are a matter of contract provision. If the Plan allows for SSDI reductions or offsets, then any overpayment must be repaid if you “opted” for unreduced benefits. In my previous posts I point out that disability insurers “front” SSDI money on your promise that you will pay it back when awarded.

SSA decides whether claims are approved or not. However, if after a review of your file GENEX decides you won’t be approved, it probably won’t take your case. GENEX won’t spend time helping you to get approved if it thinks you probably won’t be. Although Unum advertises “a free service”, you can bet there is a kickback of some kind between GENEX and Unum.

I’m going to suggest that anyone who questions SSDI overpayments and back pay should read their Plans carefully and try to understand why there is a overpayment in the first place. It’s very important to understand what’s going on before you give money back to any insurance company. Again, I’ve written several good posts dealing with the subject of SSDI and overpayments on Lindanee’s Blog.

Are private disability companies subject to HIPAA?

No, they are not. In fact, the regs specifically exclude private disability as a “covered entity.” However, your doctor, and the medical notes, or information transmitted electronically is covered by HIPAA. This is why your doctor should think twice before speaking with any insurance doctor on the phone. Telephone calls could be considered “electronic submissions” subject to HIPAA.

Is it common for Unum to offer settlements?

Yes it is. In fact, Unum, and to a much lesser extent The Hartford, are known as the “settlement mills” of the insurance industry. However, Unum will not offer settlement (outside of litigation) until it has fully exhausted every means to deny the claim, or claimants have been awarded SSDI and overpayments successfully collected. In some claim circumstances, settlement is a good way to resolve overpayments and allow claimants to walk away with a lump sum amount.

Remember that insureds and claimants are never offered the full future value of claims. Unum uses unrealistic “discount rates” and only a percentage of NPV (net present value). Anyone looking to receive fair and reasonable settlements from Unum may be disappointed, particularly for ERISA claims.

In addition, some insureds make the mistake of using long-term benefits to solve short-term debt problems. Disability settlements are generally NOT good solutions to resolve short-term debt.

Other insurance companies do not as a general rule offer settlements outside of litigation where they may be held accountable by the court.

Does Unum ever cancel a field visit after it’s been scheduled?

No, and why should they? Unum never cancels anything when they are in a position of power over someone even when it’s reasonable to cancel. Unum will enforce the policy or Plan contract in every situation regardless of whether it is reasonable to do so or not. For example, if Unum can convince someone to voluntarily attend a field visit that is not required by contract, they won’t back down for any reason.

How long does Unum conduct surveillance?

In most instances, Unum outsources its surveillance referrals for three days usually Thursday, Friday and Saturday. The company is well-known for its “tag surveillance” the day before, the day of, and the day after an IME or field visit. Unum only conducts surveillance on insureds and claimants when the company has a liability to pay benefits. (No surveillance is generally conducted prior to claim approval, or claims on appeal.)

Insureds and claimants may not realize it, but surveillance costs Unum money. A three-day surveillance incident costs between $800-$1,200 and required management validation approval before scheduled.

In the past, claims under $2,000/month didn’t justify absorbing surveillance costs, but in the last several years Unum orders surveillance, IMEs, and field visits for claims under $1,000/month. It doesn’t make sense since throwing good money after obviously payable claims is costly.

Not considering the cost overhead of risk management is a good indication of the lack of Unum’s leadership to control financial reserve losses.

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ParanoiaThe Free Medical Dictionary defines “paranoia” as an unfounded or exaggerated distrust of others, sometimes reaching delusional proportions. Paranoid individuals constantly suspect the motives of those around them, and believe that certain individuals, or people in general, are “out to get them.”

Although readers may presume this post is about disabled individuals, it isn’t. Insurance companies are “over-the-top” paranoid when it comes to managing claims. In fact, I can’t imagine any other industry entities that are running as scared because they accept the premise insureds are “out to get them.” Normally, business is conducted in good faith hoping to obtain and keep loyal customers, but in the disability insurance world insurance paranoia creates mistrust and once-burned insureds probably won’t buy another policy in their lifetime.

Most disability insurers actually design their internal claims review processes presuming guilt until proven innocent. What are insurers actually paranoid about you might ask?

First, disability insurers are delusional about the fact that treating physicians act as patient advocates and document disability when patients actually have the ability to work. This type of insurance paranoia is responsible, for example, for Unum’s multi hierarchal medical reviews that keep topping off internal opinions by more than one biased reviewer after another. “Well, one review isn’t enough to back up this denial, so let’s have another review…..and another…..and another…..”

If this isn’t paranoia I don’t know what is. The problem is, however, that having more than one Unum doctor review patient information “looks like” a fair review is given and not what it really is –  “a stacking the deck” against opinions rendered by qualified physicians who actually have treatment histories with patients and know better than any sterilized industry whether patients can work or not.

In addition, insurers will actually absorb costs to outsource medical opinions to physicians with higher credentials in order to invalidate the medical opinions of treating physicians. Although increased costs applied to individual claims are not justified by small financial reserves, most insurers will incur the costs anyway just to pad the file with supportive documentation that supports business interests to deny claims.

Most of you with disability claims may recall situations where Unum (using the worst offender) receives information from a treating physician and has it medical reviewed by an internal resource who completely disagrees.

Your treating physician again responds that you are totally disabled and Unum “got it all wrong.” Unum again forwards the rebuttal to another internal paid physician who disagrees. Your doctor now tells you that he isn’t going to respond anymore because Unum’s docs refuse to listen to what he’s reporting. Regardless of how many times your treating physicians report total disability, Unum never agrees.

Has this happened to you? How many times does a treating physician with eyes on you have to report to Unum that you are unable to work? Wouldn’t you say Unum’s internal medical review process is the result of some sort of delusion that ALL treating physicians are “out to get the company and cost it money? “Is no one disabled?” Where does Unum’s medical paranoia stop? With 3 internal medical reviews? Six?

Second, disability insurers are extremely paranoid insureds are secretly working and have not reported earnings to reduce benefits due. Most insurers run scared about unreported earnings and employ sophisticated investigative resources to “catch” insureds in the act of working. The Hartford, for example, assigns three people to each disability claim one of which is a private investigator. These “investigators” conduct multiple surveillance, activities checks, Internet snooping, credibility and motor vehicle checks etc. for the purpose of finding out whether insureds are working or not.

A Hartford investigator once told me, “Linda, you can’t imagine how many insureds are out there lying to us for secondary gain. There are thousands receiving disability benefits when they can actually work.” Is everyone presumed to be dishonest? Apparently, The Hartford thinks so.

Disability Management Services, Inc. hires investigators who actually stop peers in the parking lot to ask questions about insureds and their activities. These same investigators contact ex-spouses, rivals, and government entities to document any “scuttlebutt” they can get their hands on in order to discredit claims. Isn’t it a bit paranoid to resort to “credibility” when all else in support of claim fails?

Companies with top-heavy investigative resources presume all insureds are seeking secondary gain when in fact only 10-15 percent of disability claims filed are actually fraudulent. Even when insureds are found to be honest, insurers often “misrepresent” the data they’ve accumulated to make insureds look bad. Insurance paranoia leading to deception and “stacking the deck” is the cause of most unfair and egregious claim denials.

And, let’s not forget how profitable it is for insurers to presume guilt before innocence since those with legitimate disability claims get thrown in the garbage along with those who shouldn’t be paid at all.

Finally, insurers are paranoid about paying too many claims – period. In the past Unum’s claim directors managed the numbers by using LARs or “Liability Acceptance Rates”. Since most insurance underwriting assumes payout rates of 60%, Unum managers went ballistic when more than 60% of claims were approved and paid.

This means that Unum’s internal claims review process must consist of strategies to “stack the deck” against insureds so that legitimate, payable claims can also be denied keeping Unum’s profitability greater than the underwriting payout rate. More profit is possible if Unum not only doesn’t pay the claims that shouldn’t be paid, but a percentage of compensable claims as well.

Another example of Unum’s paranoia is during the multi-state settlement investigations Unum advertised that it was paying 98% of claims. Although this was a “reactive” statement, it was also very stupid. If I were a Unum stockholder and was told the company was paying 98% of claims I’d ditch my stock. Unum shouldn’t be paying 98% of claims either, but due to the multi-state investigation and recent media exposes at the time, Unum became paranoid and reported an even worse statistic.

Remember, disability insurers make money by NOT paying claims rather than PAYING them.

Although occasionally companies like Unum and CIGNA are caught by regulators using deceptive practices to bolster profits,  a few million here or there in fines is only a drop in the bucket to billion dollar companies who continue to sell polices they have no intention of paying in the future.

What is also unfortunate is that those who potentially buy disability insurance products have no idea beforehand what they will be in for if they ever have to file claims. Although companies such as Unum are more than willing to take premium dollars, they will be less likely to pay claims because the presumption is that insureds are dishonest and file claims for secondary gain. Unum’s entire claims process wreaks of that notion.

However, nearly all disability insurance companies operate “paranoid” and design internal review systems around the concept of deception, theirs and yours.  “Corporate paranoia” is also sold to claims handlers who quickly develop the same bias against insureds.

Honest insureds and claimants are forced to deal with “paranoid” insurers who are convinced they and their doctors are “out to get them.”

The industry has really gone amuck when honest disabled persons are forced to deal with delusional insurers who see ghosts of deception behind every claim when in reality there is none.

Disability insurance is in truth a very “mucked up product” run by paranoid profit seekers if you take the time to really think about it. I’m hoping buyers will take the time and engage in due diligence before purchasing any disability insurance product. It takes a great deal of time, energy and emotional effort to deal with paranoid organizations.

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Taking Things PersonallyOne of the most common conversations I have with disabled insureds involves the painful feelings and emotions that occur when insurance companies suggest insureds are not disabled, or are intentionally engaging in deceptive activities for secondary gain.

The emotional destruction described to me by those who experience credible pain only to be told “it’s in your head”, or, “our physician consultant determined you do not have pain at an impairing level”, is overwhelmingly detrimental to individuals seeking better health and well-being. In fact, a secondary disability develops as insureds and claimants try desperately to cope with insurers who don’t believe them.

Internalizing opinions rendered by insurance companies is a normal human reaction to criticism, accusations, repeated misrepresentations and implied wrongdoing at a time when insureds may already feel guilty and saddened by not being able to return to work and pursue their favored careers. These feelings are in addition to worries and stress related to health conditions that can be scary in and of themselves.

When insureds take things said or done by insurers personally, they interpret what insurers say or do as reflections of who they are rather than as reflections of the entity who is communicating or treating them badly. Taking things personally means “internalizing” information as part of your self rather than as something that may not really be about you.

Disability insurers often take advantage of the “vulnerability” disabled persons feel by openly accusing them of a variety of deceptive practices such as “you didn’t report the income we found on the Internet”; “we saw you walking your dog and going to the doctor so you can work”; or, “our doctors don’t think you are disabled.” Disability insurers act in certain ways, not because of YOU, but simply because that’s how the claims process works.

Insurance companies do not respect you, deliberately make you feel uncomfortable and feel badly about yourself, personally attack you for profitability sake, devalue and belittle you, and constantly attempt to bait you.

Most insurers will certainly give you “an emotional run for your money.” Unfortunately, some insureds and claimants “make bargains with the devil” and end-up giving a lot of themselves away in order to assimilate what is perceived as absolutely necessary for financial survival.

Here are a few suggestions as to why insureds take things personally and internalize wrong information.

Putting things in writing is so much worse than verbal exchange.

If a claims handler from The Standard told you nicely on the phone that a medical review indicated you could return to work, you may not agree with the decision, but it’s likely you wouldn’t react the same way reading the identical information in a 12 page letter. For some reason humans tend to view information “in writing” on a written page to be so much more official as in, ” well, if it’s in writing, it must be true”, or “seeing is believing.”

Insurance companies love to write long letters because they are intimidating and lend toward credibility the more pages that are written. In truth, most of the letters received from insurers cite the same long policy provisions over and over again causing letters to be longer than needed. The letters I often read from insurers are mostly policy citations and I actually have to look carefully for the one or two sentences that describes the real purpose of the communication.

Most insureds who receive long letters from insurers internalize the message of repeating policy provisions as fear, and by the time they read the real purpose of the communication, the damage of  “taking the message personally” has already been done. Many insureds are so fearful of opening “that overstuffed envelope from Unum” that it often sits on a table for days before the now overstressed insured masters the courage to open it. In other words, insureds often “take the message personally” before the envelope is even opened.

Something in writing will always be more intimidating than verbal exchanges particularly when it is overstuffed, lengthy, wordy and accusatory.

The insurance company does not recognize you as a person and therefore can’t treat you as a person.

Insurance companies manage claims by claim number, SSN, dates of birth and financial reserve. Claims handlers “see” you as one of between 175-200 electronic flups (follow-ups) on their desktop that they have to make contact with at least once a month. Although insureds often feel the need to express “how they feel” to their reps, the truth is how you “feel” and “why you can’t work” is disregarded information that in most instances isn’t even documented.

The process of disability claims review is sterile, robotic, and similar to widgets flowing down an assembly line. New claims are placed on the assembly line and are referred to several resources within the company for documentation along the way. Once received, claims continue down the manufacturer’s line until they can eventually be paid or denied. The claims review process does not lend itself to “personalization” even when insureds and claimants express their heartfelt emotions about being disabled. It just isn’t going to happen.

What To Do – More Easily Said Than Done!

  1. Don’t jump to conclusions too quickly when you are confronted by insurers. Take a brief “time out” and consider what the insurance company is really trying to say or obtain from you. Remember, long letters with repeated policy citations are only intended to contribute to the length of the communication and may not be the reason for it. Take a breath, and time to think about what the message from the insurer really is. (Some insureds react negatively to routine updates rather than accepting them as a normal and customary part of the process.)
  2. Create space between yourself and the insurer. Although your initial response might be to react emotionally, resist that “knee jerk” by taking time to rein in your emotions and assess what really “set you off” before you respond. This is why DCS, Inc. recommends all communications in writing – it gives insureds and claimants an opportunity to actually “think about” what their responses should be.
  3. Remember that taking things personally makes you easy prey to those who are looking to deny your claim. Unfortunately some insureds “give away the farm” by talking and writing so much to insurers. As a general rule, insurance reps pay little to no attention to comments such as, “I wish I could work, but I just can’t”, and “I would be working if I could.” Insureds should act on the same sterile level as the insurance company because all else will be misunderstood and eventually misrepresented.
  4. Taking things personally sets you up to suffer for nothing. In most instances, claims reps pull down template menus and construct letters they send to you and then move on to the next flup. In the meantime, insureds internalize each and every word and dwell on messages for weeks. If disability insurers regard you as widget jelly beans on an assembly line, how can it’s communications and actions be critical of you as person? “Suffering for nothing” takes energy away from those who should be focused on medical treatment, health and well-being.
  5. Don’t place your trust in what insurers say about you! Disability insurance companies are focused on ridding themselves of the financial reserve liability for your claim so that they can report more profit to stockholders. Every action taken is the result of internally generated strategies to “stack the deck’ against the payment of claims. “It’s not personal……it’s strictly business.” Insureds might want to also keep in mind that most of what is conjured up by insurers is misrepresentation intended to back-up denials of legitimate claims. You are not responsible for the actions of others, nor do you have to blindly accept conclusions you know to be false.
  6. Rely on yourself.  You are your own best asset. Insureds and claimants often do not give themselves enough credit when it comes to challenging deceptive practices and responding to untruths communicated by insurers. The claims process is what it is and once insureds either educate themselves to the process or retain help, “taking things personally” isn’t as destructive as it could be.

Not taking things personally is a concept that could be applied to every aspect of one’s life, not just in situations dealing with insurance.  The truth is, we are only responsible for our own actions and shouldn’t internalize the poor behavior of others.

Finally, I want to validate the feelings of those who are dealing with disability insurance and find themselves taking things personally. It’s very hard not to when a surveillance van is parked across the street watching your every move.

However, I do think it helps somewhat to know more about the disability claims process and the insurance assembly line of claims review. You are not a “person” to an insurance company; but a financial reserve number that needs to go away.

 I hope that the above will help you in some way. Please don’t let an insurance company take away your understanding of who you are as a person. It just isn’t worth it.

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Buy outAfter reading another comment on the blog admin site concerning Unum’s offer of settlement followed by a claim denial, it occurred to me that Unum isn’t the only insurer of late to get the settlement process “bass ackwards.”

In the recent past, The Hartford also approached a client about a settlement and then proceeded to request an IME with the intended purpose of denying the claim. While not all disability insurers are anxious to offer settlements those that do seem to be using the process to, 1) get the insured to agree to release private information, 2) obtain work releases from Advance Pay and Close settlements, but once obtained deny the claim instead; and 3) entice insureds and claimants to give away information that could be used to deny claims.

In the past, both Unum and The Hartford did their homework preparing claims for settlements such as updating all medical information and having it reviewed; making sure SSDI had been obtained and overpayments recaptured; obtaining waivers for mental and nervous claims; and most importantly, obtaining an internal business consensus that the claim would be paid to maximum duration.

It is standard procedure for insurers to perform their investigations prior to approaching insureds about the possibility of settlement. However, beginning in 2012, it appears insurers have reversed the process by offering the possibility of settlement first, then proceeding to investigate whether the claim would be paid to maximum duration.

My guess is that at some point, it was realized by disability insurers that the settlement process could be used as a “risk management” action to obtain information from insureds who are excited about a lump-sum buy out and turn the same information against them resulting in more claim denials.

It does seem as though Unum is “fooling around” with the settlement process since I’ve seen several client offers resembling “Advance Pay and Close” letters to claimants they couldn’t possibly understand. AP&C letters do not inform insureds of their appeal rights and are based on “anticipated expected return to work dates.”

A typical example would be for Unum’s medical department to document an expected return to work date based on the software “Medical Advisor” and then have a “commutation specialist” offer to pay-out benefits to that date. Unsubstantiated and unverified AP&C offers are unfair since insureds would have no way of knowing the consequences of not having any appeal rights or ability to re-submit medical information if unable to return to work by the date Unum gave.

This consultant has also been made aware of Unum settlement offers with inaccurate present value calculations. When questioned by the insured, the “commutation specialist” admitted claims had been under-reserved and therefore the present value was “made to fit” the reserve value maintained on the books. In general, Unum’s settlement offers do not exceed approximately 80% of the reserved value.

While the prospect of having been offered a Unum lump-sum settlement may be attractive, Unum insureds and claimants should always have these offers reviewed by an attorney, and in particular not to give away the farm on the phone when interviewed.

Until Unum’s settlement policy can be more understood, it might be a good idea for all Unum insureds and claimants to seek assistance from an attorney before communicating or signing any documents relative to claim settlements. This goes for The Hartford as well.

Insurers are not to be trusted with respect to settlement offers until the offer can be objectively established as fair, legally tendered, and offered in good faith.

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Chronic Fatigue SyndromeOn Tuesday Web MD released a report conducted by an independent panel of experts convened by the US government calling ME/CFS a “legitimate disease.” Although data suggests between 836,000 and 2.5 million Americans suffer from Chronic Fatigue Syndrome, most physicians were found to not take the disease seriously.

In particular, disability insurers in the US and efforts in Great Britain alleging ME/CFS is all in one’s head have created battlegrounds among disability insurers who refuse to pay claims and treating physicians who continue to diagnose CFS as a legitimate cause of disability.

However, Tuesday’s report by the Institute of Medicine (IOM) committee suggests renaming CFS as “Systemic Exertion Intolerance Disease” to “better reflect the seriousness of its effect on patients.”

According to Suzanne Vernon, scientific director of the Solve ME/CFS Initiative, ” The new report could prove a watershed moment following years of struggle for people with myalgia encephalomyelitis/chronic fatigue syndrome (ME/CFS), who often have had to fight to convince doctors that something was truly wrong with them.”

Ms. Vernon is also reported as saying, “I believe we are at the tipping point for people suffering from ME/CFS where we are going to be able to get people diagnosed, and with that diagnosis comes the ability for us to really lay the groundwork for much more effective treatment for ME/CFS.”

Although in the past, treating physicians had to rely on a clinical “rule out” methodology to diagnose ME/CFS, the new data suggests CFS symptoms can be treated although a cure does not exist. In 2014 the scientific community linked CFS to inflammation of the nerve cells of the brain and defects with immune responses.

According to Mr. Thompson’s article in the HealthDay Reporter perhaps the most beneficial part of the new IOM report is that it identifies new diagnostic criteria to help physicians streamline the process. According to the official report, those suffering from CFS have three core symptoms:

  • Impaired ability to engage in pre-illness levels of activities that persists for more than six months and is accompanied by often-profound fatigue.
  • A worsening of these symptoms after any type of exertion, including physical or mental exercises or emotional stress.
  • Sleep that does not alleviate fatigue.

Additionally, in order to diagnose a person with chronic fatigue syndrome, physicians must also find the patient is suffering from one of two additional symptoms:

  • Impaired ability to think, and
  • The inability to remain upright, with symptoms that improve when lying down.

The IOM panel also indicated that symptoms must last for a period of six months and present at least half of the time on a moderate to severe level of intensity. Mr Thompson also quoted in his article, Ms. Ellen Wright Clayton, the IOM committee chair, as saying she “hopes the new criteria will make it easier for people with chronic fatigue syndrome to be diagnosed.”

Ms. Clayton also concluded, “We expect and hope more research in the future is going to allow the refinement of this diagnosis. This is not a figment of their patients’ imagination. This is an all-too-common, complex disease that needs to be diagnosed.”

Although the scientific community is giving ME/CFS more and more credibility, disability insurers have no obligation to adopt the new guidelines when determining disability. However, the new position of the IOM committee will make it harder in the future for insurers to allege the disease is all in the patients’ heads.

Most importantly, physicians who in the past ignored CFS symptoms, will be able to identify and treat the disease sooner rather than later. Family physicians will also be able to identify and diagnose the disease without specialized consults from infectious disease and immunology physicians.

In addition, the position of the IOM study should interest the Brits who are still victimized by Unum’s influence in discounting ME/CFS as a legitimate cause of disability. Advocates of ousting Unum from Britain’s welfare system finally have something to support their cause for medical disability.

Although the new perspective to ME/CFS is a step in the right direction to legitimizing diagnosis and treatment, we are still a long way from convincing disability insurers that CFS patients are submitting credible claims with restrictions and limitations precluding work.

In any event, those suffering from CFS will have a much better chance of having the disease diagnosed early and treated according to a recommended medical plan.

Additionally, physicians may finally feel more comfortable in certifying disability for CFS rather than using a methodology of ruling out everything else and then putting a tag on a diagnosis not well understood at all.

This will be extremely helpful to private disability insureds and claimants who are required to continually supply insurers with “proof of claim.”

It may also be a comfort to those who have struggled with CFS to realize their symptoms have not been a result of “symptom magnification”, but are real physical manifestations of a legitimate disease.

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Red flagDespite the fact that the disability claims process is obvious and to those of us in the industry many insureds and claimants miss or dismiss the tall tell signs of insurance targeting only to be amazed later when denial letters are received. Surprisingly, after a significant history of harassment insureds often call to tell me, “I was shocked to receive a denial letter; I thought everything was OK.” Obviously, it wasn’t…….

In order to start out the new year with useful information I thought perhaps a new post describing identifiable “red flags” would help insureds recognize when they need assistance or advice in managing their disability claims. As I indicated, the claims process is generally predictable and “red flags” can be recognized if claimants know what they are looking for. Seeking the assistance of those “who know” is also an important part of the claims process.

The information below is listed in procedural order of what happens first to last in the targeting of disability claims for denial. Claimants should always attempt to distinguish between normal investigative actions that are part of the claims review process, and those that are unreasonable, harassing red flags. Insurers will always use their internal resources first before purchasing expensive outsourced investigative resources.

Continuous calls from claims specialists.  Although all insurance companies set phone interviews as job performance expectations, calls from insurance claims handlers to you and your physicians can become repetitive and harassing. This pattern of practice is often the result of some type of managerial review or roundtable wherein claims handlers are required to document a TPC, or a “telephonic personal conference.”

Attempts on the part of insurers to maintain phone contact with insureds begins as normal and customary claim investigation such as when claimants first submit their initial applications and are contacted by insurance representatives. Later in the process, however, frequent calls to insureds and their physicians become “red flags”, or indicators that something is wrong particularly when contacted weekly or even monthly. If there is any indication at all that you are working, claims specialists will call everyday at different times to determine if you are home.

No claims handler is looking to contact you because they want “updates” of information. An action in the claims process raised a “red flag” and claims reps continue to call in order to catch claimants in what is called “inconsistency of report.” Frequent phone calls are generally first indicators that disability claims may be in jeopardy. Claimants always risk damaging their claims when frequent calls are made. Human nature is such that insureds often “make up responses” because they feel compelled to answer every question even when they don’t know what the answer really is.

This is why DCS, Inc. recommends the “in writing only” accommodation.

Unreasonable requests for tax returns and other financial data. While it is normal and customary for insurers to request annual tax returns from those who are working part-time or paid residually, it is NOT normal for insurers to request 10 years of personal tax returns in an arbitrary and capricious way. (“Out of the blue” requests.) Most DI policies require the submission of tax returns of up to 5 years due to formulas used in the calculation of residual earnings, therefore these requests are necessary in order for insurers to calculate how much to pay you.

However, unreasonable tax return requests to group Plan participants who are paid total disability are red flag indictors that insurers have some evidence of unreported earnings, or are looking to determine if claimants are working in their own occupations. Unreasonable requests for tax returns and other financial data are great sources of income to disability insurers in the form of alleged over payments or reductions of benefits due to earnings offsets.

Vexatious and harassing requests to treating physicians for patient notes. phone calls and narratives. Sudden repetitive requests directly to physicians for patient notes and records generally indicates insurers have recently reviewed the claim file and found it to be lacking in medical support of claim. Although disability claims can literally get lost in an electronic data base, eventually a manager or new claims handler will read the file and find proof of claim lacking to sufficiently support total disability.

Requesting updated medical notes is a normal and customary part of the claims review process; however, harassing physicians for the same information over and over again is not. Claims handlers escalate requests for updated information just prior to the end of financial reporting periods such a month-end, end of quarter or year-end when financial targets need to be met.

While there is no need to panic when requests for updated information are received, frequent communication with treating physicians to determine how many requests are received are in order. On many occasions, physicians themselves will let insureds know when office managers begin to report frequent requests and harassing phone calls.

Narrative questionnaires sent to treating physicians are definitely “red flags” since these are typically  “communication doc-to-doc contacts.” Medical questionnaires sent to physicians in writing are always indications that internal medical reviews have taken place (roundtables) and the insurers’ medical resources are looking for treating physician “buy-in” to deny claims.

Medical narratives and doc-to-doc calls to treating physicians are never good news for insureds and claimants and the process should be managed carefully. All patients have the right to request to see all completed forms before they are sent to insurers.

Claimant Questionnaires – wolves in sheep’s clothing. Claimant questionnaires are always “red flags” and indicate insurers are looking for detailed information about daily activities. Most insureds feel compelled to “fill-up” the page with information that can be used by insurers to deny claims.

It is very common for inexperienced insureds and claimants to OVERWRITE information and literally hand over work capacity to insurers who misrepresent information on a grand scale. Remember, disability insurance policies define the inability to work at one’s occupation or job, not inability to do laundry, grocery shopping, gardening, or going to the post office for stamps.

All questionnaires and “activities inquiries” are red flags and should be managed very carefully.

Transferable Skills Analysis (TSA) between 9-18 months of paid benefits. Although most insureds and claimants generally allow the change in definition to manage itself, the entire process is actually a red flag. While conducting TSA investigations after 24 months is a normal and customary part of the ERISA group claim process, most insureds eventually find out that insureds just aren’t good at it.

“Gainful” definitions are ignored, job descriptions in the national economy are misrepresented and approximately 50% of claims paid to 24 months are essentially denied, even though insurers have previously benefitted from collecting SSDI overpayments.

Changes in definition of disability after 24 months should be managed by claimants since the process is really a “garbage-in, garbage-out” procedure. If old medical information is used going into the process, the end result is unreliable and inaccurate. Claimants should consider TSA investigations as equivalent to the type of investigation that took place to initially pay claims in the first place and treat it accordingly. The worst thing claimants can do is to allow the 24-month investigation proceed without additional input. Experienced claims managers will know what to do.

Field visits, surveillance and Independent Medical Evaluations are requested.  These three risk management activities are always used when all of the above fail to support terminations of claims In order to achieve profitability targets insurers are now more desperate and eventually make decisions to throw money into the claims pots in hopes of “stacking decks” to support denials. Field visits, surveillance and IMEs are ALWAYS red flags toward claim termination and should be managed as such.

Although most disability policies now write-in requirements to meet with field representatives and attend IMEs, internally quite a few risk management activities have already taken place before red flags reach the point of incurring additional costs to terminate claims. Surveillance is at the end of the red flag investigatory process since visual and observed activity is only useful to support otherwise weak claims for denial. Insureds and claimants are often unaware that any red flags previously existed.

Readers now may be asking, “So what are NOT red flags in the claims process?”

Frequent changes in claims personnel are NOT considered “red flags” since most disability insurers have retention problems and need to pass off blocks of claims to other handlers. Although a real pain in terms of consistency of management, playing musical chairs with claims handlers is a normal part of the process. Disability insurers can’t really retain good employees for long periods of time.

Routine updates requesting the completion of forms. Insurers have the right to request updated medical information at regular intervals and therefore there is no concern when packets of forms are received in the mail.

It is hoped that in the coming year insureds and claimants will become more knowledgable about the disability claims process and better distinguish between what is normal and customary to the claims process and what isn’t.

Hopefully, more insureds will also seek help from those who are knowledgeable and experienced in managing disability claims.

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Please helpWhile no one argues the rights of disability insurers to investigate claims fully, targeting claims to deliberately deny benefits for profit is no more keenly felt than at Christmas. Although nearly all group disability insurers engage in the same unfair internal  claims procedures, in my opinion Unum remains the most notorious egregious Scrooge of all time.

Let’s take the case of a young woman diagnosed with migraines and dementia due to suspected Alzheimer’s disease. Although Unum’s policy excludes “dementia due to Alzheimer’s” from the 24-month Mental and Nervous limitation, Unum denied payment beyond 24 months based solely on its own physicians review of a neuropsychological evaluation.

Keep in mind Unum’s physicians may still receive annual percentage bonuses for buying-in to Unum’s agenda to deny more claims. Mrs. X. received her denial letter on December 23rd and is unable to celebrate the holidays because she has no money. At least Unum stockholders will have the satisfaction of knowing they will receive dividends on their stock this year!

Of course in 2015 Unum’s escalation of IMEs, field visits and surveillance added to the thousands of total claims denied in 2015. This consultant in particular reviewed denial letters and other Unum correspondence showing evidences targeting HIV/AIDS victims, mental and nervous disorders, migraines and cognitive issues, as well as catastrophic cardiac claims alleging work capacity where none existed. Tragic as it may seem, to my knowledge Unum (and other insurers) remain unregulated by state and federal ERISA authorities who turn their backs when companies like Unum financially harms the most vulnerable among us.

Unum is by no means alone in its “stacking of the deck” to deliberately deny families of much-needed disability benefits. Despite the recent CIGNA multi-state state settlement and fine, the company continues to deliberately act with intent to deny claims in the cheapest way possible. Through its chaotic and negligent claims review process, CIGNA’s claims handlers still refuse to give their full names on denial letters. I guess denying legitimately payable claims is a lot easier when you don’t have to sign your name.

Another case in point is the Aetna claim of a single mother diagnosed with POTS and shortness of breath. Denied on December 22nd, this young mother cried until she couldn’t cry anymore. The next day, she dressed her six-year-old daughter and visited the local food pantry and Catholic Church so that she could give her daughter a proper holiday. Having also lost her health insurance, Ms. B. had no idea how she is ever going to refill her prescriptions.

For 12 years DCS has been providing insureds and claimants with information equal to that of insurers who review their claims. My theory is that if insureds are more knowledgable, it would be more difficult for disability insurers to deny benefits rightly due to them. Unfortunately, my only regret is that the information posted here does not reach all who might benefit from it.

In more than a decade, I have reviewed thousands of disability files, letters, emails, and received many, many phone calls related to claim situations of every disability insurer in the United States, Canada, and the UK. Please take my word for it….insurance bad faith isn’t getting any better.

The truth is, disability insurance hurts more people than it helps particularly this time of year. Although many of you reading this post, may not personally be aware of it, in total, there are likely to be thousands of American families who received disability denial letters in 4th Quarter and who, this holiday season, are struggling to pay bills. If your claim wasn’t denied in 2014, count yourself very lucky indeed.

Clearly, the legends of disability Christmas cannot be boasted as holiday cheer, and certainly no claim denial decision was ever celebrated as “in keeping with the holiday spirit.”

However, it has also been my experience that regardless of what lies around the corner for disability insureds and their claims, I can always rely on the courage and strength of those who continue to demand fairness and the right to be treated respectfully in good faith and fair dealing.

Were it not for those who never give up in the face of nearly impossible odds stacked against them, I would have been out of business a long time ago. Frankly, I’m the eternal optimist when it comes to disability claims, and I don’t give up either!

Happy holidays to insureds and claimants everywhere, and best wishes to all those who need encouragement and a kind word at this time of year.

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