Disability Claims Solutions,Inc. - PDF
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Insurance Disability Claims Advocacy for Private Disability Insureds Tidbits: Lindanee’s Blog is up and run- Solutions,Inc. l i n d a n e e @ m e t r o c a s t . n e t J u n e 2 0 0 9 V o l u m e I ning and is avail- able for posting comments. CIGNA over- turned ERISA National Coalition of Disability denial and bene- fits were re- Insureds (NCDI) and Lindanee’s Blog stored to our DCS client. Yea! Anyone who wishes to participate Recently DCS, Inc. reported to As of today, Chat with Mr. you the formation of a non- we have the on the Action Committee, please John Metz to see profit organization called The beginnings let me know. Lindanee’s Blog is if your claim located at: National Coalition of Disabil- of a na- situation can benefit others. ity Insureds. I want to thank tional data all of those individuals who base of phy- http://lindanee.wordpress.com Be very careful of volunteered their time to work sicians who having oral con- Please feel free to visit and post versations with on its formal Mission State- have successfully managed your comments (the link is at the any disability ment. Input from the insured disability claims. This and insurance com- very bottom of each article membership is always greatly other data bases will be avail- pany. page.) To get things going I’ve appreciated. able to clients, members and posted a few articles of interest Disability insur- their attorneys free of charge DCS, Inc. and the fee-based to insureds and I’m looking for- ers have no re- once the organization gets gard for medical advocacy services offered to ward to reading your posts. going. disability, just insured continues as usual financial re- Posting can, of course, be anony- serves. with many successes. How- Lindanee’s Blog was also cre- mous. It is hoped everyone can ever, NCDI was created for ated to open the door of com- Most internal stay connected either through the the purpose of giving a lobby munication to all insureds insurance docu- DCS, Inc. website, or Lindanee’s mentation is just voice to insureds with private who wish to document claims Blog. “full of it.” disability insurance, and those procedures and practices who depend on federal and which need to be addressed It is also hoped NCDI will even- state laws to protect their by NCDI. It is also an excel- tually become a true “coalition’ of rights to fair, and respectful lent place to keep everyone advocacy organizations and in- treatment by the disability up-to-date on what’s going sureds dedicated to helping those insurers. on that may affect the pay- with disability claims. ment of disability claims. Just Health—John Metz “Working for Health Care Justice—Now!” California News Mr. John Metz has been ad- insurers and those who work ticipate in various actions. Claim- vocating the rights of disabil- for/with them.” He also ex- ants are not limited to residents ity insureds for over 30 plains, “One step in accom- in California, therefore, if you years, and is instrumental in plishing this is to find appro- feel your claim was administered working with the State of priate claimants to be plain- in “bad faith” or, improperly, California’s legislature to tiffs in lawsuits to halt vari- please feel free to give John a enact insurance consumer ous forms of improper con- call . protection laws. Mr. Metz duct by specific insurers to describes the mission of his which large numbers of He can be reached by phone at 1- organization as: claimants have been sub- 800-878-7843, or by email jected.” email@example.com. “Our goal is to take actions to protect insureds from im- Currently, John is looking for Please call and chat with John if proper conduct by disability potential claimants to par- you if you think you can help. Page 2 When Is the Insurance Company Right? Claimants have contractual Disability insurers may also Disability insurers may also duties to the insurer the deny claims when any claim- deny claims when there is same way the insurer must ant physician agrees the in- evidentiary proof (medical, fulfill certain duties to the sured can return to work in occupational and financial) insured. One might even their own or any other occu- the claimant does NOT meet say the insurance company pation. the definition of disability in has rights too. the policy. The insurance company may When is the insurance com- deny claims when it is clear Claims may also be denied pany right? The insurance the insured does not meet because the insured’s work Of all the possible company has a right to deny eligibility requirements such earning exceed 80% of pre- reasons why a dis- claims (eventually) if it has as Elimination Period, Pre- disability earnings, or for IDI ability claim can requested medical or finan- existing Condition, Exclu- claims when the insured does be denied, failure cial information, and it has sions, Minimum Hours not have at least a 20% loss in to provide proof of not been forthcoming. Worked , not in a Covered earnings. loss shouldn’t be (Failure to provide proof of Class etc. Eligibility reviews one of them. The loss.) are first in the hierarchy of Proven fraudulent claims are insured has a con- the claims review process. also not payable. tractual duty to remain in appro- priate and regular care and provide What Do Insurers Know About Medical proof of that care to the insurance Disability Anyway? Do They Care? company on a DCS, Inc. currently manages or mental stamina to fill out an gery and suggest he/she regular basis, or several clients diagnosed with activity log every three hours, could go back to work in when asked to do Chronic Fatigue Syndrome. nor would a disabled person be two weeks? Most CABG so. Last week I received a 6 page able to complete 20 pages of an patients still have staples in “Activity Questionnaire” from application for benefits. their chests and stitches on No medical proof Unum with a request to have the inside of both legs. of claim—no bene- our client keep tract of his/ Likewise it is also very typical fit. her daily activities every few of a person who is sick to at- Imagine what the insured hours. tempt to remain on the job as must be thinking holding long as possible before stop- the phone and looking Sun Life’s application for STD ping due to financial reasons. down at themselves won- and LTD group benefits ex- Sometimes it is very difficult dering, “How in the world ceeds 20 pages of questions, for an impaired person to ac- am I going to be able to go most not relevant to the cept the fact they may not be back to my job as a truck claim. Standard and Mass able to work, or that an illness driver in two weeks? I have- Mutual also have a several will have such a dramatic im- n’t even been to rehab yet.” page “daily activity log” which pact on their lives. the insured is expected to fill It seems incredible disabil- out. Disability insurers just don’t ity insurers know so little get it, and they don’t WANT to about the personal effects If a claimant is sick, but at- get it either. of medical disability to the There’s much more to a tempts to remain on the job point of treating claimants before applying for disability, Is sending a claimant a request as though “physical or men- disability claim than for and APS and Supp State- Unum, for example denies tal disability doesn’t exist at financial reserves . It’s claims based on the “what ment really a good idea the day all.” unfortunate disability changed defense” claiming after he/she had a heart attack insurers have no idea that since the insured worked and a CABG x 5? (Coronary There is much more to a what that is. sick, they really weren’t dis- artery by-pass of five arteries.) disability claim than a fi- abled at all. The claimant wasn’t even out nancial reserve and a pay- of the hospital yet! able claim. It’s unfortunate, A CFS patient most likely though, that insurers have would not have the physical Does it make sense to call a by- no idea what that is. pass patient a week after sur- firstname.lastname@example.org Page 3 Significant 2nd US Circuit Court Ruling Against Unum Group May Help Other ERISA Folks In a 2nd U.S. Circuit Court Unum’s actions were in fact Unum’s claims practices of Appeals ruling McCauley “arbitrary and capricious.” had been unscrupulous. vs. First Unum Life Insur- ance Company the court Mr. McCauley’s attorney, After the decision Unum found that “Unum decep- Eugene Anderson of Ander- said it regrets the New York tively indicated to McCauley son Kill & Olick is reported court did not allow it to in- a medical resource assigned as saying the decision sets troduce new claims man- to review his records was a an example for other cases agement improvements it medical doctor when the nationwide by denouncing made since its handling of individual was in fact a arbitrary and capricious Mr. McCauley’s claim 13 nurse.” The company used claims-handling practices. years ago. the review to mischaracter- Federal and state ize its rational for continu- The court reviewed evi- In any case, what goes dence Unum engaged in bad around comes around— courts may now ing benefits. Although a summary judgment had faith claims practices based eventually. be operating in a been initially rendered in on the 60 Minutes and NBC much favorable favor of Unum, on appeal Dateline exposes in 2002. Payback can be real costly, environment since the court determined Media reports also reported and rightfully so. the election of a new President in the White House. The Deliberate Art of Miscommunication It may be too early to tell, but there is all It doesn’t take very long for a fact of what is actually said. “sanitizing” or removing docu- indication claims specialist to learn how Twisted documentation is con- ments from the file - the infor- changes are on the to sift through claimant dialog tained within the claim file and mation simply isn’t added to horizon. and document only what is can be eventually used to sup- the record in the first place. favorable to the insurance com- port claim denials . pany. Here’s an example. In a phone This is one of the reasons why interview the insured says to “Selective documentation” is a insureds should take great care the claims handler, “ I’m doing learned insurance skill devel- to request all phone interviews a little better lately and perhaps oped by internally listening to be submitted in writing, and I may go back to work in a few Most claims other experienced claims spe- field visits audio recorded. months if my doctor lets me.” specialists cialists and managers who ren- As a former Lead Claims Spe- Claims specialist writes this learn to “listen der critiques of documentation and suggest ways to “improve cialist I was often told by Unum down, “Claimant says her doc- selectively” it.” consultants not to document tor will release her back to and document certain actions taken on a claim work in a few months.” New claims specialists receive because the information could only that some training in writing insur- be “discoverable” in a lawsuit. Another example, claimant which is ance documentation, but the says, “My doctor started me on favorable to skill of “snatching” and The deliberate omission of some new medication and I’m documentation potentially having severe complications the insurance “twisting” takes some time to develop. damaging to the insurance when I take it.” company by company is called “bad faith by “snatching” “Snatching” is defined as the omission.” Handler writes down, “Claimant most likely not com- and pulling of key phrases from medical patient notes at the Even when copies of the claim pliant with medication.” “twisting.” expense of all else favorable to file or Administrative Record Most internal are provided to attorneys, in- Disability insurers make a lot the insured. formation in support of pay- of money pretending documen- insurance “Twisting”, on the other hand is ment of claim is deliberately tation is factual when it isn’t. documentation the skillful documenting of con- missing from the file. Compa- is just versations and interviews with nies such as Unum can no Insureds should be aware of this and exercise caution. “full of it!” a deliberate misstatement of longer be accused of Linda E. Nee, BA, HIA, DIA, DHP Office Hours: Disability Claims Solutions, Inc. 60 Hicks Rd Mon—Wed 9:00 a.m.—4:00 p. m. West Newfield, ME Thurs—Fri Tel (207) 793-4593 Fax (207) 793-2006 Dedicated to writing appeals and other communica- tions on behalf of insureds. email@example.com http://www.disabilityclaimssolutions.com Disability Claims Solutions, Incl. works with insureds, physicians, employers and attorneys to pro- vide information advocacy concerning the disability claims process. This newsletter is the property of Linda Nee and Disability Claims Solutions, Inc. It is not intended to be a substitute for medical or legal advice and all issues relative to a person’s health should be dis- cussed in detail with a physician who is licensed to practice medicine. Likewise any issues of a legal nature concerning any disability claim should be obtained from an attorney licensed to practice law. As always, please feel free to contact me with any questions you may have concerning this informa- tion. CLIENT CORNER: DCS, Inc. has had quite a few successes in the last few months overturning denials and keeping our clients paid. Although it’s a tough environment we continue to work with our clients to make sure all contractual duties and responsibilities are met. Thanks for making the extra effort to obtain the re- quested medical information updates which are very important to the disability claim process. Physicians have been contacting our office requesting the “Communicating with your Physician” bro- chure which is a very good thing. DCS, Inc. now has the opportunity to work with more physicians in communicating information to insurance companies. If your physician requests the brochure, please send me his/her email address and I will be happy to send electronically. Just a reminder, disability checks can be up to several days late around a national holiday. July 4th will be here before you know it, so please plan accordingly. I encourage everyone to keep abreast of what’s going on with NCDI and Lindanee’s Blog. I’m fre- quently posting other relevant information on the site and strongly encourage people to post their comments. Some have expressed to me how fearful they are about expressing opinions publicly. You can use a generic yahoo or Google email address. There ARE no disability claims police, or moles will- ing to spend time trying to find out who you are. Please stay tuned in and participate. Take care.