Part of the training of your average claims handler includes something I call SIL, or “selective interpretative listening”. It is presumed by the industry that there is a difference between what insureds actually say, and what the words mean in terms of risk management of disability claims.
So while insureds chat along on the phone thinking, “more information is better claim protection”, the claims handler on the other end is documenting nothing like what was actually said, but is interpreting the conversation as to what it means to claims management. Do you really want to have that conversation? Let’s see.
Insured (or physician) says, “I’m doing OK, I guess, but I am looking to return to work in about 6 months when my back pain is more controlled.” Claims handler documents, “Insured is doing much better and will be able to return to work in 6 months. Flup request updating medical in 6 months, and document return to work in own occupation.”
WOW! Did the insured really say that? Did the claims handler just set his/her “Primary Plan Direction?” The claim is now targeted for a denial in six months based on what the insured SAID, without medical buy-in, I might add. This example points out that insured should NOT discuss their own aspirations or guesstimates about returning to work. What is said, is NOT what is heard or acted upon in the future. Still want to speak to your claims handler?
Second example, claimant says, “I am in bed sleeping most of the day and almost never go outside of my apartment except to go to my doctor’s appointments and pick up my prescriptions.” Claims handler documents, “Claimant reports sleeping all day with limited activity that is not medically supported. Request surveillance and IME to confirm lack of functional capacity.” This insured just bought herself what is called a “tag IME” (Independent Medical Examination) where surveillance is ordered the day before, the day of, and day after the IME. The lesson in this example is that insureds should NOT give detail about their activities, or at least not describe it so that it can be discredited by surveillance. The first time this insured steps outside of her house and demonstrates any functional capacity the claim is gone.
I think you must be getting the idea. Something a simple as, “My doctor is on vacation for the next few weeks and won’t be able to provide the APS according to deadline”, might be interpreted as, “Claimant’s physician APS will be delayed, physician unavailable. Call office, verify vacation status, and set new deadline for submission of patient medical notes.”
Are you getting it now? Every action out of the insureds mouth precipitates a new action on the part of the insurance company, and it’s not always accurate. When insureds say, “I never said that”, it becomes a “he said, she said” situation and the insured doesn’t have a chance. This is why DCS has never recommended insureds speak directly on the phone with insurance reps, but instead ask for everything documented in writing. It’s much harder to misinterpret what is actually on paper.
When a Consultant or Attorney contacts claims handlers on the phone they are more aware of the fact that reciprocal documentation is taking place on their end, possibly even being recorded. By the way, Unum does NOT record calls on a routine basis and will become pretty rowdy if they find out YOU did the recording. The letter sent out to the insured is nasty and threatening, demanding a copy of the recording and not paying benefits until they get it. Very paranoid in context.
Finally, no Plan or policy requires insureds to speak with an insurance company on the phone. While the policies DO require insureds to provide “proof of claim”, that proof should always be in writing. As long as insureds are providing what is required to determine inability to perform one’s job or occupation, there is no other commitment to speak specifically on the phone. Claims reps always push for verbal conversation because they know what they do with the information.
I hope that my readers really listen to what I’m saying and determine for themselves whether they really want to speak with insurance reps on the phone. It’s not a recommended DCS best practice. You have to be really careful and just zip it up.
