While there are so many disability “issues” brewing for year-end 2020, I decided to write my usual Sunday Editorial about investigative actions taken by insureds that potentially can cause claims to be denied for year end profitability.
While some of the topics discussed below appear to have happened all year long, they can be used by insurers to deny claims, which we do not want, particularly at the end of the year. While much of what I’m mentioning in this article has to do with Unum, remember that all insurers basically do the same things.
First, Unum is assigning “due dates” for update information that are entirely out of contract. DMS is not far behind in alleging “late filing” when Notice of Claim was given during a 12 month EP. Nevertheless, as most of you know there are two types of contracts for disability insurance: 1) Those that are subject to ERISA, namely Employer STD/LTD Plans, and 2) Individual Disability Policies purchased separately from an agent.
ERISA Plans require claimants to provide additional proof of claim within 45 days of its having been requested. Plan language also says, “at your own expense.” IDI policies require submitted proof within 90 days after the end of any period of claimed disability. These two different types of contracts have two very different provisional requirements.
Apparently, insurers are subjecting ALL insureds and claimants to the same 45-day ERISA standard. Letters are sent to IDI insureds requiring 45 compliance when their policies DON’T SAY THAT! Therefore, although Unum and other insurers threaten denial within 45 days, they need to be reminded that they should be adjudicating YOUR POLICY and not holding you accountable for ERISA administrative standards. This issue could prove to be disastrous if Unum were to deny IDI claims based on “failure to provide” in 45 days.
When IME reports are not provided to treating physicians in a timely way, time literally runs out. Any IME report obtained by an insurance company should be reviewed by all treating physicians who then have an opportunity to respond with a rebuttal. Most of you already know that getting treating physicians to write rebuttals can take some time and a great deal of sitting on top of their offices as follow-up. Insurers are more prone to either not send the IME report, or not have time to review rebuttals before year-end.
Insurer use of the doc-to-doc call in 2020 is at its highest levels. I am already hearing that Unum has doc-to-doc calls on its priority list in order to discredit claims for year-end. Therefore, its really important that insureds speak with ALL of their treating physicians reminding them that you are not giving permission to speak with insurance doctors.
Let’s not underestimate the agenda of insurance doctors’ phone conversations; they have their ways of influencing treating physicians to agree with them. I have had so many insureds thrown under the bus by treating physicians that I can’t be strong enough with my advice, not to allow the calls. Unum is focusing on these calls for year-end because they’re profitable! Have a conversation with all of your treating physicians as a prevention and agree what steps will be taken if physicians are contacted.
Need I mention surveillance? Surveillance referrals nearly triple at year-end. Sometimes I almost see a type of “arrogance” from insureds when they tell me, “Oh, I don’t care whether they watch me or not, I don’t do anything wrong.” Well, Murphy’s law isn’t a law for noting….
When someone tells me this, I know that they just don’t get it because insurance surveillance can be interpreted in a misrepresented way that has nothing to do with whether someone is “doing something wrong” or not. How many claims have been denied because someone was observed walking their dog?
And of course, in today’s terms surveillance also includes Internet investigations, so if insureds are using social media they WILL BE FOUND OUT. I always recommend to clients that they “stay off of” social media, but not everyone listens to best advice.
And finally…..insureds need to be aware of what they say and write. This is why DCS recommends communications in writing only. Don’t take calls from insurance companies! If disability insurance were any other business transaction you’d insist on it in writing. End of the year is a very good time for insureds to document in writing that they request all communications in writing.
Insurance companies generally “go all out” in the 4th Qtr., most certainly in December, to locate vulnerable claims to deny by year-end. Knowing that, insureds and claimants need to take a “heads up” approach and not add to their own demise.
Don’t allow the insurance grinch to deprive you of your claim. Come January you still want to be receiving benefits.