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misrepresentationUnum Group and its claims representatives have been misrepresenting policy provisions for quite some time, particularly when it comes to the older policies where “rights and privileges” can be read into nearly every provision in bad faith.

There is one Unum Senior Benefit Specialist located in the Worcester claims office that is particularly nasty to deal with. More than that, this is the second time she has attempted to use an “IME Provision” in an older policy to threaten an insured into compliance with out-of contract requests.

The first time the threat occurred, she demanded a field visit was that not expressly required via contract language. In 1992, Unum’s old policies didn’t require field visits and field visits were not part of Unum’s risk management strategy at all. In complete misinterpretation of the IME provision, Unum alleged that “medical examination” included a field visit. Bunk! My client and I challenged that interpretation and won.

This time around, the same “snotty” claims handler is alleging the IME provision also requires the insured to speak with her on the phone. It’s obvious this claims handler became miffed, when the insured asked for communications in writing. This is what the letter to the insured said:

“The process you are proposing [in writing only] is cumbersome, particularly with respect to follow-up questions. The policy provides us with broad latitude regarding examination and obtaining information regarding your claim.”

I am actually astounded – Unum DOES NOT have any latitude with IDI non-ERISA claims and is expected to adjudicate the policy contract in accordance with provisions as written.

In addition, the inured’s policy is non-ERISA, has no discretionary authority, and the policy says itself. With IDI state jurisdiction policies there is no “latitude” for Unum to decide anything except to enforce the actual policy language. IME provisions are exactly that and “examine the insured” DOES NOT include phone conversations or field visits.

Based on my recommendation I refered this insured to an attorney who will soon take Unum’s demand for a phone conversation off the table. Once an attorney is involved with the claim “talking to the insured is a mute point” and Unum’s threat is null and void. How stupid can this claims handler be?

I very rarely disclose the name of Unum’s claims handlers, but if anyone is interested, please send me an email and I’ll give you her name. The misrepresentation of a policy contract is blatant and Unum should be publicly held accountable for it.

It’s clear to me that Unum needs to reign in some of its claims handlers particulary when it comes to this level of policy misrepresentation, which is really fraud. If it’s a manager who is directing the claims handler to do it, then the VP of claims should terminate the manager.

This is a perfect example of the fact that Unum claims handlers and their managers are complicit in putting forth misrepresentations, in this case to deny a claim with financial reserves in excess of $1.5 M dollars.

In any event, no insurer can use an old IME provision as a kitchen sink in which to throw every other authority to threaten an insured. If it weren’t such a serious offense it would actually be quite funny.

Unum insureds need to be aware of what they are up against, and be willing to challenge such bad faith when policy provisions are deliberately and falsely used to threaten insureds into compliance.

In my opinion, Unum’s actions constitute insurance fraud, committed by an insurance company, plain and simple.