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Posts Tagged ‘DSM-5’

Can an IME physician refuse to give me a medical diagnosis and prognosis?

Those who ask this question do not understand the overall objective of insurance IMEs and IME physicians. The objective of a disability IME is to personally view the insured for the purpose of providing the insurance industry with written reports supporting non-payment business decisions.

IMEs are NOT intended to accurately diagnose, treat, or provide a prognosis for any medical or mental condition. Since IME physicians do not have a history of consultation or treatment with those they examine, it could actually be harmful for IME physicians to provide diagnoses or recommendations for treatment.

It’s important for insureds and claimants to know and accept the truth about insurance IMEs that rubber stamp management’s business decisions to deny more and more claims. If I were an insured I would not want any IME physician to give me medical advice – that’s not what they are paid to do.

Does Unum insurance have a cap?

Unum ERISA Plans pay a percentage of pre-disability earnings, 60% being the most common. However, the Plan will also stipulate a “maximum monthly benefit” such as $5,000-$10,000. While the maximum benefit is rarely reached by the employee rank and file, benefit maximums for executives are unattractive when earnings are greater than $100,000. This is why most highly paid executives also buy IDI polices to cover the additional earnings not paid from group Plans.

IDI policies pay the “scheduled amount” of monthly benefit located on the first page of IDI policies. Scheduled benefits can be increased by exercising future income increases and policies could contain COLA that will also increase benefit. Future increase riders and COLA are often limited in the number of FI allowed, or the number of years COLA is paid.

What is a mental disorder as defined by disability insurance?

For disability purposes, a mental disorder is defined as one located in the Diagnostic and Statistical Manual, DSM-5. If you want to know whether a diagnosis is classified as mental and nervous, look it up in the DSM-5 to see if it’s listed there, or ask your therapist. If it is listed, the diagnosis will be considered mental and nervous and subject to the mental and nervous provision.

I want to go to school while I’m on disability to prepare for another occupation. Is that OK?

Unfortunately, most insurers will interpret the ability to attend school and classes as having work capacity. In fact, it hasn’t been that long ago that Unum put the question about taking courses on its forms.

Each individual claim and situation, of course, will be different depending on what the impairment is, and what restrictions and limitations treating physicians are reporting. For example, if a claimant reports fatigue or chronic pain of some kind and yet is able to sit in a classroom three days a week….well, you can easily see how the insurer will interpret that as having at least part-time work capacity. Taking online classes gives you an Internet presence that can be hacked into at any time.

This is a good example of how insurance companies shoot themselves in the foot. Training for a new job will return insureds and claimants to work, it’s just that insurers do not want to wait that long. If insurers decide you have work capacity, the claim is usually denied and going to school could be one of the reasons.

Insurers wouldn’t be asking about it on forms if this were not the case.

Who was Steve Center?

Every now and then I get questions about “ghosts” from the Unum Life Insurance Company past. I believe Steve Center was President of Unum America and was one of then most strict, but colorful Unum executives. I knew him only briefly before he retired to help his wife run their Antique store in Scarborough, ME.

Who knows when Unum’s top executives actually knew about the merger with Chandler and his wise guys from Paul Revere and Provident. CEO Jim Orr III retired as did Steve Center, taking their golden parachutes with them.

Steve Center’s reputation for lining up women against the wall to check for runs in their panty hose will probably stay with him for a long time. Women employees always knew to keep extra panty hose (and heels) at their desks.

For the most part, Unum employees were afraid of Steve Center and made it a priority to stay clear of him for as long as possible.

 

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