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Bad dudesSometimes I get the impression that some of my readers feel I am exaggerating the “bad faith” insurers engage in to create fear and hype about disability claims. While I have said over and over again my motives are to, “provide knowledge at least equal to those making liability decisions”, I still occasionally hear, “Linda you scare me to death.”

The Unum information I provide on this blog comes directly from the “horses mouth” so to speak through Unum’s letters, files I’ve reviewed, requests and information provided by former employees. The same is true when I write about other insurers. The situation I’m about to describe comes from a denial letter of a physician insured whose mental health providers continued to complete forms AND sent therapy notes, which is something DCS does not recommend.

Nevertheless,  Unum’s denial letter actually outlines the company’s own continued violation of the Multi-State Settlement Agreement. To begin, Unum attempted to speak with the mental health provider by phone. When it couldn’t reach him, Unum contacted the therapist via written communication to which the doctor responded in complete support of his patient’s disability.

Unum disagreed with the therapist’s responses and therefore stated in the denial letter, “In view of the lack of agreement between our psychologist and your therapist, we had the same information reviewed by a physician, who is board-certified in psychiatry. “The denial letter went on to say that the “board-certified psychiatrist” agreed with Unum’s report that the insured was NOT disabled.

The Multi-State Settlement regulators held Unum accountable in the amount of $15M dollars for violation of the following:

  • Excessive reliance on in-house medical staff to support the denial, termination, or reduction of benefits;
  • Unfair evaluation and interpretation of attending physician or independent medical examiner reports.
  • Failure to evaluate the totality of the claimant’s medical condition; and
  • An inappropriate burden placed on claimants to justify eligibility for claim benefits.

The very first item listed refers to Unum’s biased internal reports without any weight given to the opinions of primary physical or mental health providers. Regulators concluded that it was easy for Unum to document denials when it based opinions solely on its own internal physician reports. Subsequent amendments to the RSA requires Unum to consider and place significant weight on the opinions of providers, but of course, like everything else, Unum is not abiding by the Settlement Agreement and once again bases all liability decisions on its own physician opinions.

I don’t understand why Unum’s letters continue to make a big deal out of “board-certified” reviews since all physicians these days are board-certified. Unum really needs to review and re-write some of its letter templates.

However, no Unum physician in his/her right mind will ever disagree with a prior Unum physician’s report. I’ve personally reviewed several of Unum’s denial letters citing as many as four internal physician opinions all agreeing with the first review. If Unum’s physicians value their jobs, they will always agree with the first opinion – ALWAYS. (They might get fired, or at best, lose their bonuses after all!)

I would also like to point out that Unum’s internal physicians know exactly what they’re doing when they write reports that reject the opinions of treatment providers. All Unum internal physicians are expected to “earn their keep” and continue writing back-up for denials based on misrepresented reviews of treating physician opinions. Physicians who don’t do this are immediately fired. (This statement came from a former Unum Medical Director who was fired because he refused to change the wording in his report to a more precise denial suggested by Quality Review.)

I am always hearing from insureds, “My doctor said this…..and my doctor certified my disability….my doctor said I am disabled”. There is a universal belief among insureds that Unum, and other insurers must accept the opinions of treating physicians. This is a myth, and no insurance company is compelled to “go with” the opinions of treating physicians. In fact, the old “Treating Physician’s Rule” was thrown out by the courts a long time ago.

But, then again, the Unum Multi-State Settlement Agreement still exists.  Several months ago I contacted the Maine Insurance Department, one of the lead RSA regulators, and asked the question, “Is Unum still subject to the RSA?” The DOI’s answer was “Yes.”

Why then is Unum allowed to operate outside of the agreement particularly when additional signifiant monetary penalties can be inflicted for violations? Well, that’s the million dollar question (literally) isn’t it?

For this insured, and for this claim, the obvious violation of, ” excessive reliance on in-house medical staff” is clearly documented. In fact, in my opinion, Unum’s denial of this particular claim violates three of the above concerns regulators originally fined Unum for.

Therefore, perhaps some readers may find my articles “all wet”, but I can assure you that the denial I’ve described was made in bad faith and in violation of the RSA. It was also very timely since we are nearing the end of the 1st Qtr. and Unum’s hungry vulture is alive and well.

In my opinion, insureds should always inform their own state DOIs when violations of the RSA are evident. The denial letter I read actually points directly to  RSA violations, which tells me Unum is arrogant in thinking no one notices anymore.