In 2001, as part of the NAIC Multi-Settlement, and California Settlement Agreement with UnumProvident, it was agreed that Unum would NOT continue to backdate Mental and Nervous claims in order to deny after 24 months. It identified this practice as unfair, and Unum was fined $15M and $8M for California respectively for it’s unfair claims practices.
For example, let’s assume Unum paid claims for a long time for physical disabilities, but then at some point in time declared, “This is really a Mental and Nervous claim” and therefore it exceeds 24 months and is denied. This is an unfair claims practice and the 48 State Commissioners agreed that the 24-month M&N limitation would begin when identified by Unum and go 24 months forward, not backward.
In recent times, all insurance companies have resurrected all of the unfair claims practices of the past, including the M&N scam from Unum Group.
But, this scam involves more than just the denial that happens in the end. It begins with a Unum doc harassing treating physicians with requests for phone calls. Let’s not underestimate Unum, it has its ways of convincing treating physicians to change their reports and perspectives.The objective of the phone call is to obtain a written acknowledgement from a treating physician that patients have sedentary work capacity. The ERISA folks are most at risk since Unum’s “any occupation investigation” conveniently identifies “alternative occupations” that are gainful for sedentary capacity.
The M&N 24-month limitation provision is also misused to deny claims beyond 24 months by alleging the claimant was psychiatrically impaired and the claim should have been denied after 24 months. Supposedly, Unum is NOT permitted to “back-date” in order to deny claims.
Let me say upfront that claimants do not manage some things very well. They think they know what to do, but they really don’t, and won’t ask for help. It is perfectly normal for some individuals to be depressed when they become disabled. The loss of job, severity of the impairment, fatigue and pain can cause depression and anxiety. When this happens, insureds should ALWAYS list the physical impairments as as PRIMARY DIAGNOSES, WITH SECONDARY DEPRESSION DUE TO PHYSIOLOGICAL CONDITIONS. The ICD-10 Code for this is F06.30.
Logically, one could say, “Were it not for the physical impairments and symptoms would this person still be disabled?” The answer would, of course, be “No”. If you don’t do this, Unum, (or, any other insurer,) could allege your SECONDARY DIAGNOSIS is really YOUR PRIMARY, and deny your claim after 24 months.
Look, UNUMProvident was extremely clever in its day. It combined two major diagnosis groups and called it the “Psyche-Cardiac Unit”. Individuals who underwent open heart surgery (CABG) often became depressed and for a period of time attended therapy sessions to help with their recovery. Well, Unum often alleged that because the patient was receiving therapy, the disability wasn’t really open heart surgery rehabilitation, but depression, and denied the claim.
Unum has been playing this M&N scam for as long as I can remember and I go back to 1996 with Unum Life Insurance, and UNUMProvident. Remember that Unum is forbidden by the Multi-State Settlement Agreement to back-date M&N determinations, but it appears they are doing it again. Don’t be a victim of this kind of scam, and stand up for your rights under the provisions of your Plan.
If you need assistance with any of these issues, please feel free to let me know. DCS@metrocast.net. or Tel: 207-793-4593
