Unum – Use Of Medical Advisor To Set Recovery Dates

In the past the people of Great Britain suffered because of its welfare system’s use of something called ATOS, now discontinued. Those who applied for “disability welfare” were determined eligible, or ineligible, by a computer system (ATOS) with no human intervention. Amidst a great deal of protest and civil action, ATOS was eventually done away with.

Meanwhile in the United States, Unum (the co-inventor of ATOS), also uses a computer software called Medical Advisor (MA) to determine “when insureds SHOULD be better”.

Of course, MA doesn’t take into consideration that people improve and “get better” at different rates, and I suspect the use of MA allows the company to reduce its medical staff and require fewer RN walk-ins. I also suspect Unum may be using MA to set ERDs (Expected Recovery Dates) that are really drop dead dates for claim denials.

Recently, I received an email from someone who had been admitted twice as a mental inpatient for two attempted suicides. Diagnosed with schizophrenia, Unum continues to harass him since “he should be better in 12 weeks.” This kind of statement reeks of Unum’s use of Medical Advisor that also assumes the program is used by medically savvy claims handlers.

To my knowledge schizophrenia does not go away in 12 weeks and it is extremely inappropriate for Unum to allege this claimant can go back to work without restrictions. Having used MA myself when I was employed by Unum, it seems to me one of Unum’s village idiots looked up depression and anxiety and got 12 weeks.

Unum’s management is extremely remiss in allowing claims handlers to use Medical Advisor without adequate training. It is also acting in bad faith, if in fact the review process uses MA to set future recovery dates – really claim denial dates in disguise.

Rumors continue to abound that Unum Group downsized again and is cutting corners on the review process to the point of negligence. I heard several months ago that Unum trains its newbie U-numbies to “suspect” every claim and investigate as much as possible.

This is a philosophy that came to the company via Harold Chandler, Ralph Mahoney and his henchmen from Chattanooga in 1999. At one time ERDs were connected to financial reserves so you can see how important it was to use MA and set ERDs to the shortest period of time.  Fortunately, for insureds and claimants Unum’s ERD fiasco was discovered and ERDs were removed from financial reserve coding.

Nevertheless, it appears that Unum is once again using a medical coding software to pinpont (target) when claims can be denied. Using artificial software to determine human recovery dates isn’t accurate and Unum should know better since it never really worked the first time around.

Filed under: Claims Investigations, Claims Process