Although I’ve written several articles on “Regular and Appropriate Care”, the long buried issue of Unum’s CXC Employer Plans is once again showing it’s face in the review process.
In the mid-90’s and earlier, Unum’s Group LTD Plans were issued as series XL or XLL. You can find this designation from the middle of the Plan pages, although the Plan itself is juvenile in appearance and looks unprofessional to say the least. I saw these group policies and had to work under strict “blue memo” directions because it was very difficult to enforce Plan denials given the broad and bizarre language they contained. Therefore, management provided their own interpretations called, “blue memos.”
Just before the 1999 merger with Paul Revere and the Provident companies, Unum Life scrapped the XL and XLL plans for a new series of ERISA Plans it called CXC. Therefore, beyond 2000 Employer ERISA CXC Plans were issued correcting all former loopholes and added several new “Glossary Definitions” including Regular and Appropriate Care, Maximum Capacity, Subjective Symptoms etc. Provisional language was tightened, giving Unum management more concrete back-up to deny more claims. Claims handlers were required to attend instruction on how to administer CXC versions of the policy.
Regular and Appropriate Care, in layman’s terms, means that claimants are required to treat with physicians who have credentials in the medical expertise for which claimants have filed disability claims. This means that if claimants seek benefits for Depression, they must be treating with a therapist and psychiatrist, not a family physician. Likewise, you don’t take a broken leg to a mental health provider.
Unum’s tradition of enforcing Regular and Appropriate Care, continues because the company continues to enforce what IT determines what Regular and Appropriate Care to be. This is actually egregious, since treating physicians determine Regular and Appropriate Care based on the patient’s history, consultation, medication management and treatment. If insurance companies were allowed to dictate Regular and Appropriate Care, no one would be approved for benefits.
While this particular provision is often abused by Unum’s process, it is in the Plan that all claimants should remain in Regular and Appropriate Care.
As a Disability Consultant I find that two major problems come up with those who contact me. Either the claimants have “dropped out of regular care”, or, they are not currently treating with “appropriate” physicians who have credentials related to their particular disease.
A good example would be someone diagnosed with FMS who is treating with a family physician twice a year. The appropriate care for FMS is monthly treatment with a therapist, medication management, and consultation with a rheumatologist on a regular basis. Family physicians aren’t qualified to treat FMS unless they have a provable specialty with the impairment. Unum considers FMS a deal breaker unless claimants meet “regular and appropriate care” described as above.
I keep seeing the issue of “regular and appropriate care” in Unum’s letters, therefore, it is best to avoid the issue all together, by remaining in regular care with the right treating physicians.
If you need assistance with this issue, don’t hesitate to give me a call.
