I think there must be information in the public view that suggests private disability insurers review claims in “good faith and fair dealing.” However, those who believe this are obviously unaware of the actual claims process, because insurers DO NOT review claims fairly, but instead engage in a calculated practice of planning denials from the moment claims applications are received.
Although I’m using Unum as an example, other insurers do virtually the same things. Claims submitted to Unum are uploaded electronically at the Columbia, SC intake center and are sent to managers for distribution to claims handlers. Once received, claims handlers have 5 days to review new claims and document a “Primary Plan Direction” , (PPD) that solidifies the outcome objective of the the claim
Setting a PPD for a disability claim instead of investigating in “good faith and fair dealing” is a form of targeting that gives claims management the tools to project financial reserve roll-ins of profitability.
I want to make sure everyone understands what I’m describing here. First, the claims handler reviews the claim, decides what the outcome of the claim will be, and then “works” the claim toward that end. The liability decision is made within 5 days of the receipt of your claim when it has not even been investigated yet.
These types of procedures take away the concept of “fair and objective review”, which by the way, never happens during the review process. The idea most insurers have that insurers will look at the evidence objectively hasn’t been true for 50 years. The PPD is THE most important piece of documentation since the claims handler actually writes ahead of time what the ultimate decision will be.
For example, a typical PPD writing might say, “Clmt is oow on 1/7/2021 due to rheumatoid pain, but is not TD own occupation. Refer claim to MR for review, and deny as not disabled from own occupation.” (Claimant is out of work on 1/7/2021 due to rheumatoid pain, but is not totally disabled from own occupation. Refer claim to Medical Resource for review, and deny as not disabled from own occupation.)
While it is likely that ERDs (Expected Recovery Dates) are not used anymore, it is true that managers depend on the PPDs to determine profit objectives for their units. Managers take a dim view of ERDs gone by, or as they see it, profit lost. Would you actually be surprised to learn that at no time is your claim given a fair and objective review based on medical and occupational evidence.
This is why I hear so frequently, “How can they do that, my doctor provided a lot of medical evidence I can’t work?” Once the PPD decision is made about future decisions it is not changed, or, it can only be changed by a manager who manages financial reserve. This is targeting in its purest form, and it deprives insureds and claimants of fair and objective review.
Virtually, there are only two ways insureds can avoid the target bulls eye. First, make sure all information, forms and enclosures are properly filled out and provided at the beginning of the claim. Once the Primary Plan Direction is set, the claim’s fate is already determined. Second, insureds. need to interrupt the direction the claim seems to be headed in by making sure paperwork is frequently submitted countering the insurer’s opinion.
The mistake is when insureds are too fearful to counter anything insurers do or say in their letters. Sitting back and allowing insurers to pull the strings on the directions of claims never works out well for insureds.
