As my readers are aware, I’ve been writing articles about insurance companies and recent tendencies, particularly Unum, to deny claims using “retro” or “old” unfair claims practices. On Friday, I had the opportunity to review two denial letters, both ERISA claims, one of them with an appeal denial. What I surmised all along is actually true; and I’ll give you reasons why I say that.
As a claims consultant with 25 years experience, it wasn’t all that hard to identify how Unum is performing reviews using methods that were expressly forbidden in the Multi-state and California Settlement Agreements. One of the four claims practices pinpointed by the Multi-State Review Commissioners was the “over-reliance of internal reviews and reports”, specifically those in conflict with medical assessments communicated by treating physicians.
Specifically, the RSA (Regulatory Settlement Amendments Section B3) compel Unum to give considerable weight to the opinions of physicians and declares that Unum may NOT discount physician opinions unless they are outside of realm of acceptance of modern medicine. Therefore, Unum is required by the RSA to stop making decisions based solely on their own internal reviews.
Well, don’t count on it. In both of the claims I reviewed, Unum pushes the credentials of its reviewers, and even goes so far as to have second and third internal reviews if there is any disagreement. It’s as though Unum thinks that more than one biased internal review is better than one. Twenty years ago a physician was regarded as “super qualified” if he/she was Board Certified, but today physicians are already Board Certified by the time they graduate medical school, or finish Internships. It’s not big deal anymore and “Board Certified” physicians are no more experts in their fields than any other physician.
Second, both denials use “Occupational Review” to document “occupation as defined in the national economy”. It is true that ERISA Group Plans do not insure “the job”, but only the “occupation” as it is defined in the national economy. CRCs (Certified Rehabilitation Councilors) use Department of Labor outdated data bases to obtain capacity definitions “as defined in the national economy.” Of course, not ALL occupations are specifically defined, therefore, Unum uses its “discretionary authority” to put the square peg in the round hole to justify thousands of denials.
To be honest, I had evidence 10-15 years ago that many ERISA judges threw out the old “national economy” defense and required Unum to use occupational information more in line with the claimant’s actual job. Unum’s use of the occupational back-up to deny claims may very. well turn out to be as unsuccessful as it always was. In any event, it’s back on the table and probably will be misrepresented by “any occupation” reviews at 24 months.
The appeals denial is very strange, since the policy adjudicated was an old XL or XLL policy that was in force prior to the CDC Series in 2000. These policies are really the reason why the infamous “Blue Memos” were circulated, because the older versions of Unum Group Plans were way to general, and didn’t give the company the contractual authority to deny claims very well. So, Unum published the CDC series of ERISA Plans clearly defining what it could and could not do. Interestingly, the old XL and XLL polices are indeed ancient and I can’t imagine anyone currently at Unum knowing how to adjudicate it. The Plan itself contains no “national economy” definition, even though it was cited in the appeals denial.
In summary, Unum is using its own internal reviews as the basis for denials; it is ignoring opinions of treating physicians; the company is using “occupational reviews (internal) to back up denials; and, second and third internal medical reviews to make it appear the denial is credible. In truth, no physician at Unum will ever disagree with any other Unum physician, so having more than one review isn’t really contributing to the denial’s credibility.
Unfortunately, I predict more unfair claim denials from Unum. In my opinion, UnumProvident and Unum Group never did comply with the directives of the Multi-State Settlement Agreement other than reassessment of claims.
I have said many times that the best appeal in the world is not to get denied in the first place. There used to be a saying at Unum, “Go for the biggest bang for the buck”. This is not the time to sit back and think you have everything under control. Be smart, and find out how to manage your claim accordingly.
Unum has always been the bad apple in the barrel. It’s claims practices corrupt every other apple in the barrel, so insurance companies other than Unum are all on board with the same old claims practices.
