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Year-End Profitability Denials – A Real Reality

Here we are less than a month before “year-end profitability” results for all US insurers. Although all claimants and insureds depend on their monthly benefits for financial support, I’m sure they don’t realize each year, “how close they came to being denied.”

It’s my estimate that at least 50% of claimants and insureds are TARGETED for a process called “stacking the deck” wherein insurers stack the file with write-ups and other documentation that creates the illusion the claim should not be paid. Insurance companies are extremely good at this since they’ve been doing it for more than 50 years. Although one might think the “set-up” involves the current claim, it’s really all about setting up the file so that it will “make it through” the appeals process.

Mary Fuller, Unum’s brief Claims VP never congratulated anyone for denials until the claim denial was upheld in the appeals process, hence, “a claim denial is not really a denial until it survives the appeal.” This end-of-the-year TARGET, STACK THE DECK process begins in the third-quarter (October) and lasts until December 31st. Pending claim approvals are generally not recorded or communicated until after January 1st.

Many of my readers have probably been receiving requests for many different types of medical and other information such as questionnaires. Yesterday, I received 10 letters from MetLife about a client requesting medical information from all of his treating physicians. It’s a little late for that, but the “pressing” for more information at this late juncture means MetLife’s managers are on the warpath. And so are all of the claims managers within US disability insurers.

This isn’t a game, and it isn’t something that can be passed off, or even ignored. Disability insurers mean business because if they don’t meet their own profitability goals, there can be serious consequences such as the devaluing of their Bond Ratings by financial investment houses. Stockholders may sell their stock, portfolios (theirs and yours) suffer, and other vendors will view insurers less credible for credit. It’s not good, and insurers will use every means at their disposal to make sure they “look good financially” in their financial statements.

I have to say that my yearly articles about this are considered by readers to be largely repetitive, and since nothing happened to their claims last year, insurers figure themselves pretty safe, and Linda Nee a claims alarmist. I can assure you that the possibility of YOUR claim being denied at this time of the year is the greatest your risk will ever be.

Until….somewhere in January I usually start to receive calls about denials that are going to be costly and probably not successful. As I’ve said many times, “the best defense against disability claim denials is to avoid the denial in the first place.”

Surveillance is a big issue this year and investigators are watching for anyone who exceeds medical R&Ls. I’m hoping that my readers take this warning as serious. I would assume your claim is targeted, and act accordingly by making sure all of your paperwork is in order. Don’t speak with any claims rep on the phone, and discuss with your doctor how to handle requests for doc-to-doc calls. I’ve found that in 2022, nearly every insurer made doc-to-doc calls a “targeted priority.”

Please do not allow your insurance company to hold all the cards over you in 2022. This isn’t a game, and what I’m telling you comes from someone who’s actually been there.

This is a very crucial time of year for insurers to engage in unfair claims practices and strategies. Word is, insurers are attempting to recoup losses occurred in the last two years.

Please be mindful and smart, and avoid “getting cooked” in 2022.

By the way, Fitch rates Unum as BBB, Moody’s as BAA, and AM Best as BBB. Group STD sales were $18.3M in 3rd Qtr 2022, a decrease of 15.5% from $21.6 million in 3rd Qtr 2021.

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Happy Holidays!