Disability Claims Solutions

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Q&ADoes Prudential try to deny claims?

Prudential is at least in the top five ERISA group employers who actively seek to deny claims. In fact, Prudential is well-known in the industry for its unfair and discriminative denials of mental health claims. Patient notes are always requested, misrepresented, and cited in forthcoming denials.

In the past, even though mental health providers are not required to release patient notes, Prudential refused to pay claims unless actual mental health therapy notes were released.

Prudential also allows RNs to review claims when they are not qualified to do so in the area of claimed disability. Considering the amount of financial reserve involved with some claims, the lack of MD medical review is a very arbitrary and capricious error. Since many execs now working for Prudential were fired by Unum, the company uses the old hat Unum “claim killer” physicians as claim reviewers. It’s the same story over and over again…..Disability insurer targeting and denying payable claims! Prudential ranks in the top 5 most unfair disability claims reviewers.

How does HIPAA apply to auto liability insurance?

Auto liability insurance could involve accidental or personal injury in which medical records are requested and reviewed. HIPAA Authorizations to release medical records may still apply here depending on the circumstances. HIPAA applies to all medical records transmitted by electronic means. Amendments have been passed that include other types of transfers of medical information, but the new regs are allowing more and more information to be released with less mandated regulation.

What is the definition of the word “prolonged” when written in medical records?

This is actually a very good question and one which I doubt claims handlers would be able to answer. Looking at the disability definition of both “prolonged and repetitive”, it seems reasonable to say that since a “material” duty is defined as a “work activity that is required for more than 20% of an 8-hour workday” the work task would have to at least meet that criteria.

In addition,  “prolonged” also suggests that the work activity required is performed for longer periods of time. “Periods of time” is relative (differs) depending on the claimed disability and the task itself. For example, an administrative assistant with carpal tunnel would have difficulty typing greater than 10-15 minutes, while a claimant with FMS may have difficulty only after 1 hour due to fatigue.

This is why it is extremely important for treating physicians to determine specific restrictions that actually define what “prolonged and repetitive” is for each patient in accordance with objective MRI/CAT scan results and clinical observation.

Can Unum be charged for disability medical records?

Of course. But, claimants who are required to submit paperwork for updates must cover any costs themselves. If, however, Unum requests information directly from physicians then the doctors should bill and demand payment before records are actually sent. A beginning cost should be at least $100 since Unum always offers much less.

I have always recommended to physicians that they bill for their time,  use of resources such as copy machines, the costs of administrative office staff, and any other fixed costs related to taking harassing phone calls and generating paperwork. I find that charging Unum with the real costs of providing patient records is a dis-incentive for continually asking for the same information over and over again. Although most physicians “feel funny” about invoicing Unum, they should always send a bill when requests are received directly from the company. Perhaps my readers should remind their physicians to bill as appropriate.

What is an AP & C?

Another great question. Actually, I’ve written several detailed articles on this blog about Unum’s Advance Pay and Close. An AP & C is when Unum decides you are able to return to work and then “pays you out” up to 6 months on your claim anticipating you will be able to go back to work.

For example, claimant B’s medical doctor documented she probably could go back to work in 6 months, or worse yet, Unum’s claims handler used MD Advisor’s recovery period software recommendation to state when B can go back to work. Right away, Lucens or the claims handler will send B a letter saying they are going to give her six months of benefits in anticipation of a return to work based on the evidence they have. The letter says that if B is unable to return to work within the 6 months, she can come back of claim.

Unum used to have very specific rules regarding offering AP & Cs.

  • The claimant must agree to accept the offer of AP & C.
  • The lump sum can only be up 6 months of benefits.
  • There must be specific documentation from an employer stating that a return to work is approved and expected.
  • No ERISA disclosure in the letters is permitted since an AP & C is regarded more as a settlement, rather than a denial.

Anyone can easily see how this is abused by Unum. Usually, AP & Cs are offered prior to holidays because it is presumed by Unum that certain groups of people will need money. Let’s not sell Unum short either. Tempted by the offer of getting up to 6 months benefits in a lump-sum encourages people to think, “I’ll take the money now and worry about the return to work six months down the road.”

The problem is, what if you are unable to return to work and you want to take Unum at it’s word that you can come back on claim? Forget it. The ensuing investigation will be more intense than when you initially applied and will likely be denied. AND, you don’t have any appeal rights! Please be careful with this. When Unum dangles lump-sums of money in front of claimants they may accept the offer without realizing the consequences.