I have written so many articles about insurance claim targeting, and yet I have to say that I think readers have paid very little attention, or perhaps say to themselves, “Linda’s all wet on this, insurers wouldn’t do that.” Regardless of the attention, or no attention readers give to this subject, it is a fact that insurance companies “target” claims in order to boost profitability through financial reserve gains.
Although all insurers have some type of system in place to target claims for denial before month-end, or year-end profitability, certain insurers have always taken the spotlight on abusively using financial reserves to deny claims.
One such company is Unum Group that can specifically be identified for abuse given the numbers of increased denials just prior to periods of profitability. Last year, Unum’s targeting became obvious as claims that were paid long-term suddenly were denied based only on internal medical reviews- again.
One case in point is a claim involving an over 60 woman who was informed of the denial on February 2nd, with little to no explanation. This case was a non-client who called to discuss next steps. It’s my guess, Unum’s claims handler shut down the claim on BAS on January 31st, but took two days to inform the claimant. It is likely that the claim was “targeted” specifically for denial before the end of the year.
In the above example, the claimant was around 64 years old with a monthly benefit of $4,000 payable to age 65. This doesn’t amount to a large financial reserve gain, so you have to wonder why it was “worth it” to deny the claim. Having worked for Unum myself 20 years ago, all claims are subject to denial for profitability periods that are short of meeting objectives.
A sure give away to “profit target claims” are claims that are obviously payable based on co-morbidity of the medical information and yet Unum alleges the insured can work. Another 2021 denial was the result of a doc-to-doc call with an acupuncture physician, the most distanced from the actual claimed disability. Of course, Unum would contact a physician not directly involved, and by its own admission, it was able to convince the doc that the claimant can work.(I’ve also written very detailed articles about doc-to-doc calls. If you re interested, please search from the Home Page.)
The truth is, claims are denied for profitability sake when insurers need to bolster the numbers. Typically, claims denied nearing a profit period are the result of targeting for profitability denials.
Regardless of what your perspective is about target denials, these claims should be appealed by a good attorney. In most instances the reason for the denial is so obvious that most appeals are won. I should also mention that “targeting” disability claims is an egregious claims practice. Be smart, and contact an attorney to appeal the denial. If the time factor is just prior to a profitability period, the claim was likely targeted.
Based on my experience, it is my opinion that Unum Group is the only disability insurer whose rush to target claims for profit denial is so obvious and apparent that calling out unfair claims practices is not unreasonable.
