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Attorneys Are Not Always The Answer, And Neither Are Friends ,Or The Internet Or AI

ImageMost people believe that because attorneys are licensed to practice law, they are also experts in the disability claims process. While some, due to experience, may know more than others I doubt that very many have actually worked for a disability insurer, or have taken any courses focusing on disability claims practice. This is why smart attorneys hire expert witnesses and those with actual claims experience.

At a time when the economy forces the middle class to live paycheck to paycheck, attorneys are still charging a back/forward fee that over time will pay him/her a six figure fee. A per hour fee of $500+ per hour is highway robbery to most ERISA folks and shouldn’t be charged by any attorney who doesn’t have an extensive history with ERISA and successful litigation.

A year or so ago I started writing reports for a New York attorney who established a practice on his own. I referred one of my clients to him and he asked for a $10,000 upfront retainer fee. I told him I couldn’t continue to refer clients to him because my clients were not likely to be able to afford such an extravagant fee. I never heard from him after that. Let’s face it….most attorneys do not work to benefit you, but only to benefit themselves. I know a few attorneys who are really good, honest, and charge reasonable fees, but they are in the minority. I probably could write for hours about the ill-gains attorneys impose on insureds, but that’s a subject for another post.

I have worked with and for attorneys for the last 26 years and it has always been my observation that attorneys work basically from the “shortest distance between two points” and always, always place their fees as a priority. But, what bothers me the most, is that I have personally observed situations where attorneys accept disability cases they essentially know nothing about, frequently avoid doing anything to appeal, preferring settlements, or taking cases to court, which is where their money is. I’ve witnessed attorneys who tell claimants, “Oh, just go ahead and agree to meet with the field representative” when the requirement to do so isn’t even in the ERISA Plan or policy. Attorneys do not seem to support adjudicating the policy in force and then wonder “what went wrong.” Of course, attorney do have their place in the disability claims process, but it should always be in the area of litigation. AND CLAIMS MANAGEMENT IS NEVER ABOUT LITIGATION, although attorneys often want to take you there.

While attorneys can be an unfortunate, expensive choice, the Internet is also not the answer.So many times I’ve heard from insureds, “I found it on the Internet!” Many years ago, my father used to say, “Well, it’s in the newspaper, it must be true!”, people assume the same thing about accuracy from the Internet. THE INTERNET IS THE WORST PLACE TO ACCEPT INFORMATION AS ACCURATE.

To make matters worse, some insureds have it in their heads to ask AI to help fill out their forms. I hope for your sake that you haven’t done that because the forms you submit require signatures testifying to the TRUTH AND ACCURACY of the information. Do not ever use AI to complete or fill out anything having to do a disability claim. You can never testify in court that YOU completed the forms, nor can you testify that the information is accurate. Please DO NOT EVER USE AI TO COMPLETE DISABILITY FORMS OR CONSTRUCT ANY LANGUAGE OR RESPONSE RELATIVE TO A DISABILITY CLAIM.

Likewise, peers, friends, family members and others are also NOT good sources of help, information or assistance. All disability claims are unique and represent differing situations and medical treatment. Your claim is unique and it cannot be compared with other people’s claims, even peers who worked for the same company.

In many ways, all of these inappropriate choices described above indicate how much insureds are unsure of their claims management decisions and how anxious they are to have someone backing them up even if it costs a 6-figure fee over time. My suggestion is to not assume “an attorney” is the best choice to manage your claim. Attorneys are litigators, not claims managers; they view “management” as a waste of their time (and money) and, as a result they aren’t very good at it. It is concerning that so many people are choosing to retain attorneys who may not be able to produce the results they are looking for.

ImageIf you are looking for assist you with your claim please feel free to contact me at: lindanee.dcs@gmail.com, or visit my website for more information.

http://www.disabilityclaimssolutions.com

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What You Tell Your Therapist Can Be Used Against You

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It is extremely important for those receiving benefits under the mental & nervous provisions of their policy to be aware of an unfortunate circumstance that could result in the denial of claims. While it might seem to be totally unfair, let me reassure you that it definitely  is.

The process of treatment for mental health and claims reporting coincide when it comes to private disability. Claimants and insureds attend regular therapy sessions and literally bare their souls to another human being who will write all the detail down in what’s called “patient notes”. These same “actual psychotherapy notes” are sent to an insurance company that is well aware of the “bare the soul therapy” source who will then use them against claimants and insureds to deny claims.

The problem is that insureds suffering from mental health issues should share their deepest thoughts and anxieties so that the therapist can provide appropriate treatment. The relationship between therapist or psychologist should be one of trust and complete confidence. If everything you say is then provided to an insurance company looking to limit or deny your benefits, how truthful and honest should you be?

Insurance companies aren’t dumb and claimants should not make the mistake of thinking  they are. They know the fragile relationship between therapist and patient, and take full advantage of it.

It is important for mental health disabled persons to understand that while therapists may be doing a great job, they aren’t usually knowledgeable about disability claims unless they’ve dealt with them in the past on multiple levels. When asked to do so, many therapists just send insurers the “actual psychotheapy notes” without even thinking, or reading the Authorizations; and, there goes your entire life sitting on top of a claims handler’s desk.

Therapists are NOT REQUIRED TO PROVIDE ACTUAL PATIENT NOTES EXCEPT IN THE CASE OF SUBPOENA. Your therapist can simple say, “I do not provide actual therapy notes to any outside third parties, however, I am happy to provide mental restrictions and limitations in summary form.” “Summary form” means filling out a form. While insurance companies may cause you and your therapist to think they are required to provide the information, it simply isn’t true.”

It is very important for all insureds to discuss with their therapists what to do when requests for patient notes from insurers are received. Your therapist can send a fax stating the above, but most importantly, there should never be a doc-to-doc call, and clearly, the notes are not to be provided. Patient notes belong to the therapist; they are NOT required to send them. This does not at all relieve your therapist from the responsibility of supporting your disability on a form, but it does mean the therapist can refuse requests to provide the notes.

There have been insurers in the past who have INSISTED on reviewing patient notes even when they are making out-of-contract requests. Prudential Financial is an expert in using patient notes to deny claims. I once had a claim that was denied when a female client’s notes said her boyfriend was living with her, but he wasn’t working. Another claim was denied because a very prominent client admitted to his therapist they he parked in the woods to have sex.

But, it is often more than this. Another example is that of a physician who told his therapist that he was planning to fly to Texas to visit relatives. The notes described how proud he was of himself to be able to fly on a plane without someone else accompanying him. Flying on a plane is always considered to be at least “Light work capacity,” and visiting relatives also indicates the ability to work. This is all the insurance company would need to see in order to deny a claim for “does not meet the definition of disability….has work capacity.”

There must be a discussion with your therapist either to NOT document life’s situations, feelings and activities, or NOT provide the notes when requested to do so, or maintain a second set of notes. After all, how honest would you be in your therapy sessions if you knew everything you said would be seen by an insurance company?

We all have different personalities. Some of us are not great talkers, we keep silent, but there are others who talk incessantly without taking a breath. And, by the way, to be clear, this is what therapy sessions are for. Sharing and talking about your life. You aren’t doing anything wrong by speaking your truth to your therapist. BUT……

You do have control over where the information goes, and how it is used after-the-fact. If you do nothing, but censor your discussions with your therapist, then I would question the overall value of the therapy.

My advice is to speak with your therapist about what you want to happen to your actual psychotherapy notes. And, my recommendation is not to agree to release them. If you want to receive valuable therapy, you need to be able to speak honestly in your therapy sessions without having that information released to entities who intend to harm you.

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Employers Who Stack The Deck Against You

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Although the disability claims process is intended to be administered in a fair and objective way, it rarely is. This is true particularly when it comes to “national accounts” (greater than 2,000 lives) self-insuring its own STD/LTD.

These large corporations exercise far too much control over the claims process dictating medical review outcomes, contacting treating physicians for added medical review write-ups, and enforcing so-called rules that may or may not be applied to all employees. As self-insurers, they never seem to know their place as employers, but rather attempt to dictate the terms of the claim the way they want.

In some states where large HMOs are located, such as Kaiser in CA, large employers often hook themselves up with medical outcomes related to their companies. While this is an easily recognizable unfair claims practice, unfortunately larger national employers HAVE THE CLOUT to manage the claims process as they see fit. The interests of employees under the law is secondary to the conflict of interest that exists by companies who profit from their own denials.

While it is surprising to me that most employees who are dealt a stacked deck  during the claims process continue to support their own employers as “caring, and sympathetic, and willing to help them,” it is not true that all employers manage claims fairly. Although I am not on the Board of any large corporations, I did sit in on many of Unum’s “National Account” meetings where employers were present. Their attitudes toward their own employees would surprise you.

Enter in: Sedgwick. I have managed claims involving Sedgwick for two decades and I can tell you the company remains as hard-necked as it ever was. Sedgwick is used as a third-party administrator by large-scale self-insured companies. It follows a strict definition of a large set of rules that administers disability claims “strictly by the book”, never allowing claimants to miss a deadline, due date, or phone calls. The company is also known for calling treating physicians, sometimes more than once a day.

The company is relentless. At times it refused to recognize legally appointed ERISA representatives, requiring a complaint to the US Department of Labor. It is no accident that “National Account” employers use Sedgwick as a third-party administrator. So much for sympathetic, caring employers.

In the end, large employers only have one primary objective and that is to replace the disabled worker with someone who can work the required number of hours and do the job tasks as they are intended to be done. That’s it. The truth is, some large employers have such a convoluted disability program that they themselves often do not understand. What is essential, though, is that employees understand their employers’ disability process so they can obtain the benefits owed to them.

A large employer in the state of Michigan sets of a 100%/50% payout of some sort of salary continuation until all of the sick time, PTO and vacation pay is redeemed. Then, they offer a RAC (rehab program) of finding an alternative job for a minimum of 9 hours, or, two years of unpaid medical sick time. If this is impossible, the employer refers the claim to Sedgwick who in their terms, “adjudicates an LTD Plan that is total disability only. Are you kidding me? What about this disability plan is actually favorable to the employee?

It’s important to realize that not all employers are there to help you. They definitely are not.

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“My Chart” And Other Public Records

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In today’s world there are many public forums keeping track of your medical history including patient notes. In order to make it easier for insurance companies obtain medical information about you, many insureds allow direct access to My Chart. This is a big mistake.

To begin, if you give permission to your insurance company to have access to your medical records through My Chart, you will never have control over what your insurer obtains, reviews, sees, who they talk to, or how many times insurers contacted your doctors. In other words, the amount of medical data seen by your insurer will also include medical procedures and physician contacts that DO NOT have anything to do with your claimed disability.

Recently, I was recently retained by a client who worked for a very large company with self-insured coverage for short-term disability. The employer got carried away and obtained all medical records from My Chart and actually contacted a PT facility to ask for an amendment to a Functional Capacity Evaluation. This sort of thing is really an unfair claims practice and points directly to the abuses that can happen when access is given to My Chart, or whatever data program is available in your state.

It is far better to only sign insurer Authorizations to obtain records directly from treating physicians, or request your insurer let you know what they need, and then you provide it. This way you can control who is asking for what, and when it was provided. My Chart is usually available to all hospitals and treating physicians. Multiple physicians can have your entire history at their finger tips for each patient. However, it is NOT a good thing to allow insurance companies full access because they can obtain any records they want, behind your back so to speak, and you do not want that.

So, my recommendation is not to sign any Authorizations giving permission to a self-insured employer or insurance company to have access to My Chart. Insist that insurers let you know what they need for records, and then you get them and send them in.

ImageIf you need assistance with your claim please feel free to contact me at:

lindanee.dcs@gmail.com or for more information about my services visit my website at: http://www.disabilityclaimssolutions.com

 

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Disability Insurance And Multiple Sclerosis

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Multiple sclerosis is a disease which can be slightly impairing, moderately impairing, or totally impairing. It is diagnosed with either a brain MRI that identifies lesions, or by a spinal tap. While one would assume total disability with this disease, insurers beg to differ and insureds may wind up fighting for their benefits.

As a disorder of the immune system, MS often manifests itself slowly in the form of fatigue. Insureds report not being able to work as many hours, or complain of being very tired in mid-afternoon. Frequently, insureds also report the inability to think clearly, the more fatigued they become. Those working in stressful jobs, or with a great deal of exposure to the public, often find themselves a victim to mental confusion and muscle fatigue in the afternoons.

Fatigue is a whole body inability to perform physical or mental tasks. However, insurance companies view “fatigue” as subjective, meaning it cannot be clearly defined, and is different from one person to the next. Insurers will tell you that there are many people who have MS but continue working, and while that may be true for some, it’s not for everyone. Those who file for disability after a MS diagnosis citing moderate to severe fatigue might have a challenge with the insurance company that may not consider fatigue impairing.

What is the diagnostic criteria for measuring “fatigue”? There isn’t one. Fatigue is usually diagnosed with clinical consultations with a physician. What is the diagnostic tool for measuring cognitive confusion, or in the inability to solve problems? At some point a neurologist may order a neuropsychology exam to determine the degree of cognitive deficit. And so will the insurance company if the insured claims cognition problems as a result of MS.

As indicated, depending on the specific kind of MS diagnosis, the disease begins by manifesting fatigue, and then over a period of time is progressive in accordance with the number and severity of exacerbations. Some patients can have MS for longer periods of time and not be affected, while for others with different types of MS, it is a short struggle. Insurance companies generally DO NOT have a problem paying for MS claims that have progressed to difficulty walking, imbalance, leg pain etc. However, in the early stages of the disease where fatigue and cognition problems are the only signs, insurers most often deny claims.

Supporting an early MS claim depends on the skill and thoroughness of the neurologist when filling out forms. It has always been my experience that neurologists are reluctant to be specific with their diagnosis, using words like “rule out….”, and particularly with their restrictions and limitations from work. It’s almost as though being “specialists” they don’t want to look like idiots should their patients suddenly get better.

I have always noticed that the problem insurance companies have with paying early MS claims is due to the lack of data provided by the treating neurologist. For some reason, these specialists just don’t to go on the record and say, “this patient is currently totally disabled from sustaining work.” Even when evaluating with a neuropsych test, neurologists drop the ball just short of certifying disability

I think it’s very important for insureds to speak candidly with their neurologist and make it clear they cannot work. I have always recommended taking a copy of your Job Description with you and pointing out exactly what you can and cannot do. But, please be aware that you may be in for a fight filing for disability when diagnosed with MS in its early stages.

ImageIf you are looking for assist you with your claim please feel free to contact me at: lindanee.dcs@gmail.com, or visit my website for more information.

http://www.disabilityclaimssolutions.com

 

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Living With A Disability Claim – In The Beginning

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Here you are. Can’t work anymore, and had to leave your cherished job. You’re worried, disappointed and already missing your co-workers. Upon leaving your job you were handed a stack of application forms to complete in order to file your disability claim. You don’t feel like it. You’re in pain and sick. You really want to sleep and take a nap. Your employer keeps sending you emails, and the insurance company is trying to call you every day. You’ve remembered you need to make another appointment with your doctor. You’re mentally exhausted.

I can’t tell you how many people have contacted me over the years when they’ve had to go out on disability, and become unglued by their health, the situation and the process. Almost immediately, the individual has lost something valuable to them and the grieving process begins. While every persons reaction to the loss of a job and good health is different, I’ve noticed everyone goes through the five stages of grief. Here they are.

  1. Denial. In the beginning most people deny their disability will last a long time. “Oh, I’m going to go back to work, don’t you worry.”  All newly disabled persons are convinced they will be able to return to work short-term. Mostly, its doesn’t work out that way. The problem is that people have a tendency to tell the insurance company they’re going back to work and that causes big problems when they actually can’t. When the optimism sets in try to adopt a more “wait and see” attitude so that your health can be fully diagnosed and treated.
  2. Anger. Most insureds develop anger especially when they begin to deal with their disability insurers. But, it’s more than that. People get angry at themselves, their employers, their families and other groups because they are no longer able to work. The loss of a career, such as medicine, the law, for example, that cost a great deal of money preparing for is hard to bear. I have to say that in my experience, on both sides of the fence, any loss of a job creates emotional response and it’s hurtful, and people can express that as anger.
  3. Bargaining. Sometimes insureds try to bargain with their physicians so they can go back to work even when it’s not really feasible. Or, trying to bargain with the insurance company, or bargaining with yourself, “If I keep on this diet, I won’t be sick anymore.” The third stage of grief is tryin to bargain yourself out of permanent disability.
  4. Depression. The next step is usually some degree of depression and feels of helplessness “that you can’t do anything about it.”  “There’s no point,” some insureds tell me, I’m hurt, angry and feel as though I’m depressed all the time. “I lost my job that I love so much and I miss my pager.” (Neonatologists and anesthesiologists usually tell me this.) The loss of job and the uncertainty of the future is depressing, even for those without a disability.
  5. Acceptance. Eventually, insureds finally reach the point where they accept their disability and inability to return to work. They’ve learned how to deal with the insurance company and have accepted the help of their support group. The former optimism  of returning to work is long gone. Adaptation is the norm, and while it still hurts not be be able to work, the individual focuses more on their health.

Leaving work because of a disability is not the end of life but the beginning definition of a new quality of life you hope to live. The process of filing a claim can be daunting for sure, but eventually with or without help, insureds live on with new interests and talents. I believe in the saying, “When God shuts one door, he opens another” because I’ve seen it happen to so many of my clients. And, sure, you’re going to go through the five stages of grief, but in the end you will redefine yourself all over again.

ImageYou are not alone. There are experienced people who can help you with your claim. If you’d like to learn more please visit my website located at:

http://www.disabilityclaimssolutions.com

or email lindanee.dcs@gmail.com

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Conflict Of Interest – Employer And Insurer

ImageMost people either aren’t aware, or don’t realize that for ERISA claimants there is an obvious conflict of interest. You may have read many times on my blog that the two parties to an ERISA Plan are the employer and the insurance company. Employees are referred to as “participants” or “beneficiaries” to the Plan, but actually aren’t owner of anything.

Many people who contact me tell me how helpful and sympathetic their employers are when they have to go out on disability. I think sometimes that employees exaggerate that kindness and then want to believe it. Im reality, employers are NOT on your side.

Consider the following:

  1. Employers have a vested interest in making sure there is an employee in your position doing the job the way the employer wishes it to be done. It doesn’t help employers to have vacant positions.
  2. Employers who are NOT self-insured are not happy when employees go out on disability because it increases their “experience rating” and that affects premium. Self-insured employers don’t want the added expense of paying out of pocket for STD either.
  3. While both the employer and insurance company are fiduciaries to the Plan, the insurance company is the Plan Administrator. Self-insured employers are the Plan Administrator. Both have accountability to act on behalf of the claimant, but they rarely do.
  4. Whatever the employer knows about your claim, the insurance company does also and vice versa. This is why I do not recommend getting particularly chatty with an employer.
  5. Employer policies require employees to use up their PTO and sick leave continuation pay before paying for STD. This isn’t actually employee friendly because it moves out the beginning date of STD.

Most people don’t realize that the purpose of HR is NOT to protect them, but to protect the company from Human Rights lawsuits relating to employment laws. Although HR is responsible to answer your questions, it’s never a good idea to give HR medical facts.Unum, for example, used to “sit on” Human Rights complaints, or “lose” the paperwork. Employees only have a certain number of days to file a Human Rights complaint. You might wonder then, who it is that support YOU, the employee, when you go out on disability. And, the answer is: “No one.” You are on your own, even when you think HR is on your side.

While writing on this subject, I should also mention for the Non-ERISA people that “agents” are also NOT ON YOUR SIDE. Professionals often tell me they know their insurance agent so well that they invite him to dinner once a months. The key word here is AGENT. Agent for who? The insurance company of course.

Your insurance agent does not represent your interests but those of the insurance company. And, by the way, insurance agents know enough to sell you a policy, but have no idea how it is adjudicated. Insurance agents are not permitted to make legal Notice of Claim on your behalf by requesting paperwork because they represent the insurance company. Your insurance agent has a conflict of interest because they receive royalties as long as you keep paying your premium. To rely on an insurance agent to help you manage a claim is a mistake.

When the process seems unfair, it usually isn’t. Don’t be surprised when your employer stomps on your tail. It’s expected.

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Beware: Mental Health Claims

 

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By far, the majority of claims currently brought to my desk involve mental health. I’m not going to speculate why that is, it’s just a fact that more people are filing behavioral or mental and nervous claims. As a result, more and more claims end after 12/24 months. It’s very important that anyone filing for an M&N claim be aware that benefits are limited.

The claims abuse actually begins much earlier when insurers do two things: 1) If there is also a claimed physical disability, insurers will allege the secondary “depression” is really the primary diagnosis just to limit benefits to 24 months, and 2) Request SSDI files under false pretenses to obtain Federal Form 831 where mental approvals of SSDI are listed. From there, insurers obtain actual psychotherapy notes and actually “read into them” work capacity. In fact, Prudential is an expert in doing this.

Both therapist and insureds need to be cognizant of the fact that company Authorizations do not give permission to release actually therapy notes. In fact, Unum’s general authorization (in the second paragraph) states, “Does not include actual psychotherapy notes.”.

Of course, Unum doesn’t read its own Authorization and sends it to therapists as permission to release the notes. In addition, therapists do not read the authorization and release the notes. Insureds need to be aware of this and point out the limitation to therapists. If your psychotherapy notes ARE released, it will be without your permission. I know you don’t want that.

Insurance companies generally have a standardized view of behavioral health. It is presumed that if properly medicated, and patient receives ongoing CBT (Cognitive Behavioral Therapy), they will be able to return to work within 12 months. If insureds cannot return to work within 12 months, it is presumed that either the insured is not properly medicated, or is receiving the wrong therapy. This is the time when insurers often require neuropsychiatric tests to prove their point.

This, of course, does not include some of the more serious diagnoses such as Bipolar, or Personality disorders. PTSD falls in the category of “Depression”, and is managed just the same. In any event, it is “preplanned” in most cases that mental health claims are alleged even when there is a physical disability, and are denied within 12 months.

DCS has never recommended to therapist that they release actual therapy notes to insurers. In my opinion, the actual benefit of therapy is lost when insureds do not share information because they know it will wind up on the desk of someone at their insurance company. Therapy notes ARE NOT WRITTEN FOR THE PURPOSE OF SUPPORTING OR NOT SUPPORTING PRIVATE DISABILITY. Therapy notes are the property of the therapist and are written as reminders of what transpired during the therapy sessions.

Insurance companies use the information from therapy notes to claim the insured has work capacity. In another example, Prudential denied a claim when it was discovered the insured had a live-in boyfriend who didn’t work. Insurance companies can get carried away with their own illusions, and for the most part mentally impaired insureds were done in by their own statements to therapists.

Therefore, it is very important for those suffering from mental health issues to know how to manage their claims at a time when they are least likely to be able to do it. My recommendation is to read what your Plan or policy says about mental health limitations and financially plan accordingly.

ImageIf you would like more information about coming onboard as a DCS Client please feel free to contact me by visiting my website located at:

http://www.disabilityclaimssolutions.com

lindanee.dcs@gmail.com

Tel: 207 793-4593

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Workplace Elder Discrimination “My Brain Is Not A Squishy Donut!”

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I think it’s fair to say that most disabled insureds are over 50, and some are looking to return to the workplace. Returning to work after the age of 50 can be very difficult in some states since the perception of the elderly in our culture has definitely changed from the “voice of experience” to a “crazy old coot with with a squishy donut brain.”

In Maine, for example, employers consider workers over 50 as poor risks, frequent offenders of sick leave, and not open to working outside the box. This is why I see so many elderly supermarket people bagging groceries because it is presumed their minds are now “dumber than a donut.” Just after the UNUMProvident merger, employees over 50 were offered voluntary retirement to get them out of the company.

Somehow the elderly have gotten a bad rap when it comes to working over 50. Highly specialized occupations may be more accepting with higher credentials, but in general, finding work is very difficult, even for those who are not returning to the workplace after a period of disability.

It’s a bit funny, well, maybe not so much that prospective clients sometimes apply their own elder prejudice to me. Despite the fact that I have been self-employed for 25 years, people still ask me about my age. I’m still running a very successful consulting business, and that’s my answer. Discrimination at any age, for any reason probably isn’t a good thing.

I encourage my clients to return to some sort of work if their health allows them to do it. Working is healthy, and despite what our culture tells us, 70 is the new 50. Today, the elderly have a much broader and more detailed knowledge about health, nutrition, and how to take care of oneself in view of changing disclosures about food, water and plant cultivation. It’s possible for those who are 50 years old now, to be able to live much longer lives. And, why shouldn’t they be able to work if they want to?

I also think in our current culture there is a tendency to shut out the elderly because we don’t have our cell phones stapled to our heads. We’re not conforming to Generation Z and lived when life was conventional and more normal, and that just doesn’t fit in with popular life styles in the modern world.

BUT, the elderly know things. They have the experience to solve problems, be more objective, are slow to react preferring to think things through. There are those in our society who would tell you these qualities are not good things. Still, hiring someone over 50 brings a stabilized and knowledgeable perspective to the workplace. So, if you are over 50 years old and want to return to the workplace, don’t give up. Your brain is not a “squishy donut” and you’ll do just fine.

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Self-Insured Employers Aren’t On Your Side

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So many times I hear claimants telling me “how good their employers are” and how helpful they are when applying for disability. I quickly remind them that the two parties to an Employer benefit Plan are the Employer and the insurance company. Many times, it turns out that employers have third-party administrators (insurance companies) who actually review claims and render ATP (advice to pay) to the employer. These entities are also NOT on your side. Probably the worst of these administrators is Sedgwick who always seems to be on the employer’s side.

The purpose of HR Departments is NOT to help employees, it’s to protect the employer from possible employment and human rights violations. Those claimants who can’t stop talking to HR usually find themselves in trouble eventually. Employees applying for disability are risking their claims when they just can’t stop talking to HR, or even peers left behind. Keep in mind that employers do not want to pay claims any more than insurance companies do, and are very hard to get information from.

Employers basically:

  1. Want all employees to return to work in some capacity. The costs of recruitment can be staggering, not to mention a reasonable training period. Although the ADA (American’s with Disabilities Act) appears to be favorable to employees and claimants, it is not. It does not guarantee employees a job when they return to work, and gives employers many reasons why they don’t have to hire back those on disability, or offer accommodations.
  2. Refusal to provide copies of the Plan. Under ERISA employers are only required to provide employees a SPD (Summary Plan Description), but not a copy of the Plan adjudicated by them, or an insurance company. The insurance company tells you, “Get a copy from your employer”, and vice versa. Claimants often find themselves going back and forth between the two entities trying to get a copy of the Plan. The truth is both the employer AND the insurance company are fiduciaries to the Plan and should provide a complete copy of the Plan when asked to do so. As strange as it may sound, employers often cannot provide claimants with a copy of the real Plan because they don’t have one themselves.
  3. Self-insured employers will have access to your medical records, particularly if there is no third-party administrator. Usually, the insurance company will redact any mention of your medical issues, but not all companies do this.
  4. Employers also manage FMLA and often get mixed up. In order to approved for FMLA the doctor must document an END DATE. Employers often use the FMLA endnote as a claim end date, and that’s not what it is at all. The physician should be advised on how to report an end date where it is clear, it is not intended to end benefits.
  5. Employers are not on your side Period. The employers’ goals are to have a person sitting in your seat doing your job. It can be you, or someone else. As I mentioned, so many claimants tell me, “But, my employer is so good to me, and very nice.” That’s probably true through STD, but when you transition to LTD and it’s clear you aren’t coming back, HR attitudes suddenly change and things take a turn for the worse. Suddenly, a demand is made that you come back to work, or be terminated, but that’s always a possibility after the FMLA 12 week status ends.

Therefore, it’s not such a good idea to get real chatty with employers. What HR is told by you is always used to review your claim. Insurance claims handlers are in touch with HR all the time. Be careful here and realize what’s at stake.

ImageIf you are interested in finding out  more about coming on board as a client, please feel free to contact me via my website located at: http://disabilityclaimssolutions.com, or email: lindanee.dcs@gmail.com.  Tel: 207-793-4593

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Any Occupation Investigations And How They Affect Your Claim

 

ImageAs you are probably aware, LTD policies contain a change in definition of disability that requires claimants to be disabled from working in ANY occupation for which they have training, education and experience. While this definition may seem similar as the definition of disability used by the Social Security Administration, it is slightly different and is managed in an entirely different way.

Between 18-24 months, ERISA LTD insurers will begin “an any occupation investigation” to document whether or not the claimant, based on his/her restrictions and limitations is capable of working in ANY GAINFUL OCCUPATION.

This investigation is indeed a garbage-in. garbage-out procedure if up to date restrictions and limitations are not used. Therefore, the investigation itself depends on the expertise of claims handlers performing it, if reliable results can be depended on. Unfortunately, claims handlers today are not trained in the process and if “any occupation investigations ARE done, they are done poorly.

Typically, the claims handler updates all medical R&Ls, then attempts an update phone call. Then, the claims are forwarded to some sort of rehabilitation unit, (I’m not convinced these exist anymore), and computer software is used to find alternative jobs the claimant can do that are gainful. The issue of GAINFUL has been one of my criticisms for years since the issue of GAINFUL is not addressed, or documented anyway. Each ERISA Plan should define what will be considered GAINFUL. Usually, the definition of gainful is located in the Glossary of the Plan; the most common definition being “60% of indexed pre-disability earnings.”

Again, it is unlikely that any claims handler will know how to determine how to INDEX pre-disability earnings. Basically, indexing uses inflation ratios to convert pre-disability earnings to equal purchasing power taking inflation into account. It’s quite a process, which is why it is also poorly done.

If alternative, gainful occupations are found, the claim can be denied. But, the question is always are the results of the any occupation investigation reliable. Most of the time they are not.

Most claimants just automatically take the insurers’ word that the result of an any occupation investigation are accurate. The truth is, however, that up to date restrictions and limitations are missing, and there is no proof the evaluator considered GAINFUL or INDEXING. INDEXING during the Trump years probably won’t make a difference, but in the Biden years when inflation was considerable, it could have been responsible for the denial of claims.

Depending on how much money a claimant can afford to spend, it is possible to have your own “any occupation investigation” done. It costs around $1,200 for a good one and not everyone can afford to spend money at their claims. It’s important to know, though, that when insurance companies conduct any occupation investigations, they are never done correctly, and your “goose may be cooked” before you even know it.

ImageIf your claim is approaching 18-24 months of paid benefits and you would like more information about coming on board as a DCS client, please feel free to contact me.

My website is located at: http//www.disabilityclaimssolutions.com and you can email me at: lindanee.dcs@gmail. com

Tel: 207-793-4593

I am looking forward to hearing from you.

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Medical Proof Of Claim And When It Doesn’t Help

 

ImageMedical “proof of claim” is perhaps the most important information required for disability benefits. In fact, for twenty years I’ve always told people, “no medical, no claim.” However, in today’s terms (after COVID), the tendency for physicians is “the shortest distance between two points” to complete disability forms within a 15 minute office visit. Sorry, but that’s not good enough.

It has been reported by physicians that up to a third of their practice is filling out disability forms.You can imagine, then, that physicians just want to make the problem go away. Medical for disability reporting purposes should be specific and detailed enough so that the insurance company will accept the doctor’s conclusions as cause for disability and pay benefits.

Here is my list of what a good update form should report, signed by your doctor. By the way, your physician can add additional pages to insure all of the information is recorded.

  • Documentation of a primary and secondary diagnosis including ICD-10 codes. There does not have to be a secondary diagnosis, but if there is one, it should be listed.
  • Detailed Restrictions and Limitations should be written. Please note that because disability claims are payable for the “inability to work”, R&Ls should also be written with that in mind. Example, “This patient is unable to work in any sustainable or consistent job in which he/she would be unsuccessful.” Or, “this patient is unable to return to work in his/her own occupation pending further treatment, testing, and consultation.” Phrases such as, “Can’t work”, or, “out of work” won’t help you get your claim paid.
  • Statement that R&Ls are consistent with the diagnosis and that your symptoms have worsened, stayed the same, or that you are at Maximum Medical Improvement “MMI”.
  • Statement that your frequency of treatment is considered “to be regular and appropriate care” given the history of your diagnoses, severity of your diagnosis, and is required as ongoing consultation.
  •  A full discussion of the doctor’s TREATMENT PLAN and allowable daily activity recommended.
  • A list of medications, prescriptions and dose.
  • Date of next visit.
  • In the signature section at the end, the doctor should list all of his/her Board Certifications and Specialities.

A few physicians are refusing to fill out the FUNCTIONAL CAPACITY” section of disability forms because they say, “we don’t evaluate physical capacity”, which is true. However, insurance companies don’t expect the physicans’ responses to be the same as an FCE, just an OBSERVED WORK FUNCTIONAL CAPACITY BASED ON OFFICE VISITS. Still, because disability is inter-connected with the ability to work, the Functional Capacity part of the form really is a RESTRICTION section indicating the patient’s ability to sit, stand, walk, in an 8-hour workday. Some physicians just don’t get it, and refuse to fill out the section.

As I said, physicians are now filling out the forms hastily and, of course, supportive claim information is not included. Insureds should ask their physicians to do a good job with the forms. It will save him/her from getting multiple requests for the same information.

ImageIf you would like to explore coming on board as a client, please feel free to visit my website for more information at: http//www.disabilityclaimssolutions.com. Or, send me an email to: lindanee.dcs@gmail.com

Tel: 207-793-4593. I am here to help you and look forward to speaking with you.

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What DCS Can Do For You In 2026!

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Having an expert to assist you with your claim in 2026 can make the difference between a denied claim or a paid one. While disability insurance companies target claims for denial, what are YOU doing to ensure your claim is well supported and paid?

Although there can never be any guarantee of outcome (insurance companies are flakey enough), having an experienced and well qualified person helping to assist with your claim can help you manage through an already paper driven process.

Most people who are familiar with me already are well informed of my credentials. In brief, let me just say that I spent nearly nine years as a Claims Specialist for Unum Life Insurance and UnumProvident, several years working with attorneys as an expert witness, and have successfully run Disability Claims Solutions, Inc. for over twenty-five years. I successfully  assisted attorneys with eight-five litigation cases and settled, or won them all. By the way, my company has a success rate of 99% and most of my clients are receiving continuing benefits. I also passed the State of Maine’s Life & Health licensing test and am required to take 24 CEUs every 2 years.

Working with someone who actually managed claims provides invaluable insight into the actual internal claims process. I began DCS, Inc. with an objective to provide insureds with information equal to that of the insurance industry – namely the claims process. It’s very helpful when you are working with someone who knows the minds and motivations of those who are managing claims.

Today, claims handlers aren’t as trained as they used to be, and it is still important for all claimants and insureds to understand their Plans and contracts. As a disability claims contract specialist, I can interpret policy provisions and help you understand important provisions you need to know for effective management.

Please consider contacting DCS, Inc. for more information regarding how you can become a client. Remember, your insurance company may be “stacking the deck” against you and your claim. Knowing how to manage the process in a successful way will help you support your claim in the best possible way. I can do that.

ImageIf you would like more information on how to become a DCS client please visit my website located at: http://www.disabilityclaimssolutions.com. You may also email me at: lindanee.dcs@gmail.com . Together I can help you manage your disability claim with experience, expertise, and a successful history of resolving conflicts and issues with disability insurers.

Remember  it is far better to be proactive with managing claims successfully without having to deal with an expensive denial. I look forward to hearing from you and working with you in 2026.

My website has a much more detailed description of my services.

 

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Managing PTSD As A Disability Claim

ImageBefore the 1980’s PTSD was psychiatrically managed with different names such as depression, fear, sleeplessness, etc. However, after the Vietnam War it became obvious that Post Traumatic Stress Syndrome was a separate diagnosis and the group of symptoms were identified as one disease. Once PTSD was recognized as one disorder, the door was opened for new research, and a better understanding of symptoms and treatments.

By definition, the name PTSD was changed in the DSM-5 to Trauma-Stressor Related Disorders wherein the patient must exhibit a set of symptoms outlined by the CDC and American Medical Journals.

PTSD is more clearly defined as the result of a horrendous event involving death, serious injury — or the threat of either to the patient or someone else, causing intense feelings of fear and helplessness. Symptoms of PTSD include flashbacks; nightmares; avoidance of people, places, or thoughts connected to the trauma; and hyperarousal, including hyper vigilance, insomnia, and irritability.

By “specific” criteria I mean:

  • At least one re-experiencing symptom
  • At least 3 avoidance symptoms
  • At least 2 negative alterations in mood and cognitive abilities
  • At least 2 hyperarousal symptoms for a minimum of a month

In addition, there are the “Four F’s of PTSD:

  • FIGHT – seeking safety, rages, bullying, narcississtic behavior
  • FLIGHT -flees for safety, stays busy all the time, overreacts, perfectionism
  • FREEZE – shot down, brain fog, disassociate
  • FAWN – attach for safety, co-dependency, people pleasing, repression of self

There is a great deal of information on the Internet now about PTSD, some of which is very detailed. However, for those claiming PTSD as a primary diagnosis for a private disability claim, it will be difficult to support a PTSD claim unless therapists and psychologists are aware of the criteria and can document those symptoms that specifically relate to their patients. Without documentation of specific diagnostic criteria, a claim for PTSD is hard to support. A mere mention of “PTSD” on an update or application form is insufficient evidence to support paying a benefit.

The next problem is that PTSD is considered a behavioral disease and insurance companies will require actual psychotherapy notes as “proof of claim.” The exact nature of the catastrophic trauma causing the PTSD will be known to the insurer. Like other hard to support diagnoses to support, like fibromyalgia, lupus, etc., PTSD must be fully documented as to the symptoms listed by the CDC and others before it is accepted as a disabling disability.

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What Does Your Plan Or Policy Say? First Point of Reference

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Many claimants and insureds are now report receiving letters or notifications by mail that are dated two weeks earlier. In addition, claims handlers are requesting updated information of all sorts using what I call “short deadlines.” Physicians are receiving letters and forms requests with return dates of 5-10 days. Claimants are desperately trying to work within those “short deadlines” when the request is OUT OF CONTRACT. Unfortunately, if there’s no push back, the claimant and insured musto is lost.

Here at DCS, I do not allow requests for short deadlines to prevail. Most, if not all, ERISA plans give claimants 30-45 days to provide “proof of claim” when requested to do so. IDI contracts give insureds “90 days after the end of a claimed period of disability.” (Every month is a “claimed period of disability.)

Physicians who receive requests for medical information go crazy when given 5 days to provide the information. ERISA provisions regarding returning update information also apply to your physician.

Trying to work within a 5-10 day “short deadline” is nearly impossible, but be careful here.

I’ve also seen examples where the insurance company initially requests a legitimate return date, which is NOT MET by the claimant; then, gives the claimant 10 more days to provide the information. This is legitimate. You need to look back to the original letter to count the days. I always hold insurers to the policy provisions when it comes to update due dates, and I’m recommending claimants do the same.

Incidentally, any letters or snail mail received by claimants and insureds should be dated and signed on the envelope documenting when it was received.

I don’t know when, or how it happened that claimants and insureds began to think that they don’t have to meet deadlines (when they are legitimate), by claiming, “I’m so sick I can’t do it”, or, “I hit a bad patch and just couldn’t fill out the paperwork.”

That’s not going to work. Claimants and insureds should NEVER miss deadlines using the excuse, “I’m so sick I just can’t fill out the paperwork.” Why? The insurance company doesn’t care how sick you are, and if you skip several deadlines, your claim will be denied. Yes, claim deadlines can be extended, but the key is keeping the claims handler informed as to why the deadline should be extended. BUT, IT SHOULD NOT BE BECAUSE YOU CLAIM YOU ARE TOO SICK TO FILL OUT THE PAPERWORK.

Legitimate reasons for requesting update extension is the unavailability of your physician within the requested deadline. Or, perhaps you need the deadline to coincide with your appointments. Nevertheless, I wouldn’t try to use the excuse “I’m too sick to complete the forms” excuse for missing deadlines.

ImageIf you would like to receive help with your claim, please feel free to contact me. If you are looking for additional information please visit my website located at: http://www.disabilityclaimssolutions.com, or email lindanee.dcs@gmail.com.

Tel: 207-793-4593

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ERISA Initial Claim Review Process

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Most insureds are unaware that there is a hierarchy of review that takes place on claims before any other review is done. Claims NOT passing the initial inspection are denied and no further review takes place. Before I continue, though, I need to remind you of certain facts related to ERISA claims.

Employees are NOT part of any Employer provided ERISA Plan, which is why they are called “participants”, or “beneficiaries to the Plan rather than Insureds. The two parties to an Employer provided ERISA Plan are the employer and the insurance company. When a claim is filed, the employee is referred to as a “claimant”.

Employers are required to only provide employees with an “SPD”, or Summary Plan Direction. This document is NOT the Plan itself but a summary of all of the “initial” provisions of the policy that deal with eligibility. It is this review that I would like to address in this post.

Here are a few of the initial file review provisions that are initially examined before any claim can move forward in the process.

  • Class of Employee–Tiers of employees who are covered. Benefits may be different between classes of employees, such as day workers or management.
  • Elimination Period–A check with the employer is made to determine the employee’s last day worked (“LDW”) and whether the employee satisfied the non-working days. Although this may appear to be straight forward, it often isn’t, such as in the case of using PTO and sick leave first before satisfying the EP, or consideration of severance pay and salary continuation, all of which affect when the EP begins and ends, and the 1st benefit pay date. Sometimes the number of non-working days needs to be counted to determine when the EP is satisfied. All information necessary to complete the EP review is obtained from the employer. Incidentally, claims handlers today are not trained to do this review and it isn’t usually done well.
  • Minimum Number of Hours Worked. Some employees are so totally unaware of this provision that they may cut down the number of hours worked to the point that they aren’t eligible for STD/LTD at all. Most ERISA Plans cite 20-30 required hours worked in order to be eligible for disability coverage. Claimants going back to work after a period of disability are unaware that when they return part-time , they must work the number of required hours in order to remain covered.
  • Pre-Existing Conditions. Nearly all ERISA claims cite the standard 3-12 pre-existing provisions requirement. Basically, if an employee goes out on disability within 12 months of the Effective Date of Coverage (“EDOC”), a three month look-back investigation is done to determine if the claimant took prescribed medications or received treatment with 3 months of the EDOC.
  • Benefit Calculation. Not all employees receive the same percentage of benefit, and therefore, the claims handler must verify the salary or wage with the employer and then require a W-2 or other verification of earnings from the claimant. Earnings calculations is included in this review.

While there are additional items that need to be verified such as occupation, the claims handler is required to obtain all back-up documentation for the above review and make sure it is in the file. The bad news is, I doubt very seriously whether today’s claims handlers are trained enough to do this kind of review.

I mentioned earlier there was a hierarchy to the claims review which means if the claimant fails any part of the initial review, no further review or investigation is done. For example, if a claimant files for disability because they had a MI (myocardial infarction or heart attack), but doesn’t meet the Elimination Period, or hasn’t been working the required 30 hours, there is no point to investigating medical information. The claimant is not eligible for benefits even though the MI was serious.

The initial review procedure is, and should be, very detailed and exacting. But again, today’s initial review isn’t done well and I am finding more and more errors with benefit calculations and EP determinations.

It is important to remember that medical proof of claim is often NOT the most important consideration in the claim review process.If you go to my website located at: http://www.disabilityclaimssolutions.com there is a white paper there called LTD 101. If you would like more information please visit my site and read more about the initial claim review.

ImageIf you would like to learn more about how to become a DCS client please feel free to contact me at: http://www.disabilityclaimssolutions.com, or call 207-793-4593.

lindanee.dcs@gmail.com

 

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Carrot & Stick Awards for 2025

ImageBased on my experience in managing disability claims in 2025, the top three unfair insurance companies were:

  • New York Life
  • The Hartford
  • Prudential

It seemed to me that New York Life didn’t have a clue when it came to managing disability claims. Lost paperwork, poor customer service, calls dropped, missing claims handlers, you name it New York Life did it. What I found particularly interesting was that those involved with claims didn’t seem to know about ERISA and were shocked when I held them to standards. NYL is also a very untimely insurance company, and therefore receives very poor marks from me.

The Hartford always was an insurance company dedicated to reviewing claims to deny rather than to pay. At one time The Hartford had three claims handlers associated with each claim, one of which was a surveillance expert.It is also very hard to contact, and its communication system is so convoluted, it may take a week to contact anyone who knows what’s going on with claims.

Finally, Prudential still engages in claims review practices that tip over into unfair claims review, such as allowing RNs to review medical information and make decisions to deny millions of dollars in financial claim reserves.

It’s for this reason that I give the number one STICK award for 2025 to New York Life. You may notice that I haven’t mentioned Unum, which is a good thing.

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The Importance Of Financial Reserves

 

ImageThe single most important thing about disability claims from the insured’s point of view is knowing about financial reserves and how they affect claims management. Although I’ve written many good articles on the subject of “financial reserves”, it’s clearly time to do so again.

In fact, if insured’s aren’t well informed about financial reserves, it is unlikely claims can be managed well because so much of the internal claims process depends on this one key figure. So, let’s begin.

Despite what you may have read or heard, while insurance companies do use medical information as proof of claim, there is an entirely separate review conducted by senior management long before medical reviews take place. Limited to senior and executive management, claims are reviewed and sorted in accordance with their financial reserve value. (Incidentally, insurance companies always try to keep their financial reserve figures secret because they wouldn’t want anyone to allege claims are approved/denied because of the impact of the financial reserves.)

A financial reserve is cash money required by your state DOI and SEC to be put away to pay claims on which liability is admitted (at least temporarily). Large portions of this money are portfolio invested to receive dividend and interest, which ultimately reduces the cost of claims. However, increases in Financial Reserves increase liability and decrease profit. Approved disability claims increase financial reserves, increase Balance Sheet liabilities, and reduce profit. Approved claims decrease profit.

On the other hand, the opposite is also true. Decreases in financial reserves (denials) decrease liabilities and are immediate contributions to profit. A lightbulb should be going on for you right now. Simply put, claim approvals decrease profits and claim denials increase profit. Management doesn’t really care about you or your disability. The important objective is to decide/write a claim “Primary Plan Direction” describing how to deny your claim thereby reducing financial reserves and adding to company profit. You might even say, every action taken on your claim is toward this end.

Unless, insureds really understand financial reserves, it’s likely they won’t ever understand the concept of “targeting”, or what the term, “biggest bang for the buck” really means. My definition of this saying is “the highest contribution of profit per $1 financial reserve value.” Or, put another way, the higher the financial reserve of a claim, the more a denial will contribute to profit, hence “biggest bang for the buck.” Or, said yet another way, the higher a monthly benefit is, the higher the financial reserve, and the more a claim denial will contribute to profit. Get it now?

What does it mean then when I say a claim is being targeted? Anytime claims are identified as potential denials, or contributions to profit, the claim is said to be targeted. These claims receive the lion’s share of risk management activity and never seem to be left alone. Again, claim denial via “the biggest bang for the buck.” This seems to indicate that those insureds with the highest monthly benefits receive the worst red-flag level of risk management activity in order to deny claims for the most impact to profit. After all, why spend your time trying to deny a claim with a $800/month benefit when you can go after a much bigger buck? Insurance companies have really got this down.

Most insureds internalize their disability, (which is normal), and want to assume that the most important consideration of their disability status is “medical information.” One of the most important things for all insureds to realize up front is that no insurance company cares about you, your disability, or life, except how it could be used to deny your claim. Once you really understand this basic principle about disability claims, you may be able to better support your claim.

This discussion of financial reserves is by no means the tell all about the subject, but it should give you a better idea of how insurance companies view claims.

ImageIf you would like more information, or would like to learn more about how to become a client, please feel free to give me a call or visit my website at:

http://www.disabilityclaimssolutions.com

lindanee.dcs@gmail.com

 

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Do You Need Help With Your Appeal?

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One of the trends of managing disability claims is that claimants and insureds are trying to manage by themselves without paying for additional help. As a result of that, I’m getting more calls from claimants whose claims have been unfortunately denied.

After checking with several attorneys who are now asking outrageous back/forward fees,  claimants who called me were looking for expert help without the six figure fee that went along with it. I used to do appeals a long me ago, but after winning them all Unum recognized how much money I was costing them and I had to fight for my right to represent claimants in the Portland business court.

It was decided that I would not be allowed to represent insureds up front with the insurance company, but that I would still be allowed to assist claimants with their appeals should they decide to file appeals on their own. In other words, my attorney and I won with a compromise.

It really doesn’t matter, though, ERISA allows claimants under ME Title 24A 4 (A) and to wit ERISA 29 CFR 2560.503-1(b) (4) “claims procedure of an ERISA-covered plan cannot preclude an authorized representative of a claimant from acting on behalf of such claim in pursuing a benefit claim or appeal……” to chose a representative for claims management as well as for appeals.

As I mentioned, in the last several months, (not my clients, mind you) four claimants contacted me to assist them with their claim appeals. To date, WE WON ALL FOUR APPEALS.Now, that’s quite a record. Although I did not represent my clients up front as a lawyer would, I was able to help them in gathering appeal information, obtaining appropriate medical to support claim continuation, and assistance with the appeal cover letter. I feel really great about knowing there are four people out there receiving benefits who might have lost them permanently, or at a staggering cost.

Experts can make a difference when it counts. Although there can be no projections as to outcome, having an expert on board to provide assistance can make a difference between a denied claim, and a paid one. Remember, I’ve been managing claims for over 25 years, and you can use that knowledge to help you, whether you need claims management or appeal assistance.

ImagePlease feel free to contact me about your claims management, or appeal. For more information you may go to my website located at: http://www.disabilityclaimssolutions.com

or call: 207-793-4593

My email is: lindanee.dcs@gmail.com

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Dealing With Inefficiency

ImageThe changes that have been made in the claims review process since COVID have already proved to be disastrous for many insureds attempting to work through the system on their own. Please read the various changes that have made managing your own disability claim more difficult.

  • Lack of cohesion and centralized management over the claims process that produces fair and objective decisions in a timely way.
  • Diversification of the claims review process so that no one internally “reviewing claims” has a macro view of the entire process. Division of claims review into minor tasks creates total chaos that is nearly impossible to penetrate particularly without appropriate supervision.
  • No one claims handler can answer questions about everything involving disability claims. Handlers are told how to perform their own little job tasks but can’t answer questions outside the box.
  • Minimum training on how to “adjudicate” a disability Plan or policy is provided. Claims handlers are NOT decision makers and even those who are do not know enough about contracts to make decisions involving millions of dollars in financial reserves.
  • There is no centralized management of hundreds of claims handlers working independently all over the world. Communications are strained and sporadic at best.
  • Claims handlers openly display rude and sarcastic attitudes when dealing with insureds. Most are “A-type” personality people hired specifically “not to give away the farm” and have no compassion or understanding for disability. Remember the claims manager who said, “Insureds are not worth anything, but you just like to see one tumble down the stairs every now and then.” This epitomizes how insurance companies view insureds.
  • There doesn’t seem to be any cohesiveness to the review process. There is generally not any one person who can answer questions about your claim. Customer Service bit the dust quite a while ago, so we shouldn’t be surprised when it’s difficult to get someone knowledgeable to talk to.

The real question for insureds is how to deal with chaos, inefficiency, and negligence in order to ensure benefits continue to be paid.
Here are my recommendations:

  • It is essential that all communications must be provided in writing only. No one within the company is documenting accurately, or remembering anything you say.
  • Stay away from insurance websites, even when you can upload or download information. It is not wise to keep checking the portals because they may not be up to date. Frequent checking of portals also indicates anxiety, which for most disabled persons just adds to their problems.
  • Make sure all of your communications are added to your official file (Administrative Record) or claim file. I don’t believe there is any such thing these days as an unsanitized file.
  • Make sure paperwork is sent in on time.
  • Do not “put up with” receiving letters two weeks after the date written on the letter. Never accept short due dates. Enforce your policy or Plan giving you 30-45 days to return requested paperwork.
  • Keep track of who you are speaking to. Print out fax confirmations of receipt when faxing paperwork.
  • DO NOT speak with claims handlers on the phone. Insist they contact you only in writing.
  • If you can’t understand the claims handler you’re speaking to, ask to speak with someone who can speak better English.
  • If you need help, ask for it.
  • File a complaint if your insurer acts outside of what would normally be considered “fair and equitable claims practice.

It is not easy to have to deal with businesses that are so inefficient. If you cannot defend your Plan or policy, consider retaining experts who can help you.

ImageIf you wish to contact me, or want to obtain more information about my services, please visit my website at: http://www.disabilityclaimssolutions.com

 

Tel: 207-793-4593

lindanee.dcs@gmail.com

 

 

 

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Changes At DCS

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I’m  hoping that my clients are still reading Lindanee’s Blog. If you are, then I have some news for you that you might want to make note of.

I’ve purchased new technology and have started anew with keeping file information. As you may have realized, I haven’t published a Newsletter  in several months. Now that I have a new system to enable me to do that, I will once again begin to send out the Newsletters.

However, I’m auditing the files from PayPal and will only include those Clients who have paid their renewal fees for 2025-2026. If you have not paid your renewal fee, I will assume you are no longer a client and won’t include your email address on my distribution list.

I have enjoyed working with all of you and wish to thank you for your patience. My working email is: lindanee.dcs@gmail.com. I hope you enjoy what is to come from me in 2026. More and more information will also be published on my website located at: http://www.disabilityclaimssolutions.com.

Best wishes in the coming year and Merry Christmas!

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Year-End Christmas Grinch

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Most people don’t realize that, potentially, their claims could have been targeted in October (beginning of 4th Qtr.) for denial by year-end.

We are only three weeks from the end of December and I can assure you that insurance companies are working eagerly to find any cause to allege you do not meet the definition of disability in your Plan or policy. Year-end is the final profit objective and claims can be denied in 2025 even when managers know they don’t have cause.

I’m finding that insureds and their doctors are pushing the envelopes when it comes to deadlines. I also find insurance companies are asking for information much sooner than the policy allows. Both of these together are causing an uptake on “failure to provide denials.” Insurers are also denying requests for extensions that take deadlines beyond 12/31.

Since insureds are more inclined to try to manage their own claims, more and more denials are coming across my desk. In my opinion, “failure to provide denials” shouldn’t happen. Claimants and insureds have a duty to provide continued proof of claim and should be prepared to do that within 30-45 days of being requested to do so. I know I’m going to sound harsh when I say this, but there are insureds out there who “are so much in pain, or, so fatigued……or, weak, that they just can’t fill out the paperwork,” or so they tell me. They also can’t afford to pay someone to help them, and cry on the phone, “What am I going to do?” Well, you have to complete the paperwork and send it in. If paperwork is delayed nearing year-end, the claim surely will be denied.

So please, don’t give the Christmas Grinch cause to deny your claim before 12/31/25.

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When Surveillance Happens On a Claim

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Insurance companies aren’t stupid. They realize the value of a dollar and set specific perameters that must be met before surveillance is conducted. Considering that the average surveillance costs between $1,000-$2,500 per 3-day observation and investigation, it is not likely insurers will be throwing their money out the door for no reason.

Nearly all insurance companies do not conduct surveillance on low value claims. Internally, “chasing the biggest bang for the buck” is still a good idea, so low monthly value claims aren’t worth the cost of surveillance. Risk management can take place another way, for example, repeated medical reviews. This seems to suggest that an $800/month claim is less likely to be surveilled than a $6,000/month claim. That’s actually true. What I’m saying here is that insurance companies will generally be willing to pay for surveillance of wealthier claims determined by financial reserve figures.

Secondly, surveillance is only conducted for 3 days, usually Thursday, Friday and Saturday. That’s it. Insureds who call me in a panic that their insurer has been watching and following them for a month, are probably letting their paranoia get the best of them. If you’ve been asked for an Independent Medical Evaluation (“IME”), surveillance is likely to be conducted on the day before, the day of, and the day after the exam.

In the past, surveillance was so easy to spot – cars sat across the street with blackened windows, and videocameras hanging out the windows. Today, you probably won’t spot a surveillance team since they can digitally record you from 5 football fields away. Of course, you also won’t be aware of the online tracking investigation that is also likely to take place. Things are NOT what they used to be.

Surveillance is a “risk management” tool that actually contributes to profit considerably. But, insurance companies use their financial sense and only order it selectively. In the meantime, it does no good to continually panic and fear insurance surveillance behind every bush. It’s not happening. As a general rule, surveillance is conducted because there are inconsistencies in reported R&Ls. For example, you say you can’t do something, but there is evidence you really can.

For those receiving disability benefits, surveillance is always a possibility. In reality, it doesn’t happen all that often.

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Rant, Rant, Rant, Argue, Argue, Argue

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Sometimes it’s very hard for insured’s to realize that the only obligation of insurers is to pay their claims. Once an insurance company investigates a claim fairly, and pays it, it is meeting its obligations under the terms of the Plan or policy, and you have not been harmed financially.

Unfortunately, some insureds become so angry and enraged that they never let the insurance company alone with petty complaints for this, and requests for that. As we say in Maine, “it’s better not to POKE THAT BEAR.” I can’t tell you how many times I’ve brought good news to a Client, only to have them pick several other complaints they want me to enforce.

I think this is because so many insureds are literally put through hell trying to get their benefits paid that they develop a “you tried to get me attitude, so now I’m going to knit pick you to death in return.”

I can tell you from 25 years experience that there is nothing to be gained from “getting huffy” with an insurance company. “You didn’t do this, and you didn’t do that…..you didn’t follow-up, you lost my paperwork,” etc. are all examples of what I call the WHO DUNNITS”. And, the WHO DUNNITS won’t continue to get your claim paid, particularly when claims are on appeal.

Sometimes insureds just can’t bring themselves to be happy even when an insurance company finally pays them more than $100,000 in back pay. They still want to fight, many times over some sort of petty thing. My strategy is to professionally get things in the official file or Administrative Record, and then let sleeping dogs lie. There is a time to be happy the insurer is paying your claim, accept the victory, and stop complaining.

Most insureds understand that it is better “to pick the fights you can win.” I’m speaking administratively now; I’m not talking about legal battles involving policy or Plan interpretations, or fraud. (Unfair claims practices where you actually can prove “intent” to harm you.” NO INSURED SHOULD WANT TO EVER GO TO COURT WITH A DISABILITY CLAIM. It is not like it used to be, and I’ll let you read between the lines as to why you wouldn’t want to do that.

Bottom line, there does come a time when insureds should just calm down, be happy they are getting paid, and STOP picking fights with their insurance companies. It’s just not worth it. Rant, rant, rant doesn’t work anymore. In some cases it just makes you look crazy. Accept your claim victories and just move on.

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Zip It!

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Many years ago when I was still giving expert testimony in disability cases and depositions, the attorney would tell me in no uncertain terms: TO SHUT UP! “Yes” and “No” are still very good answers they would tell me. “If you continue to speak, you’ll just be giving the opposition more ammunition to come back at you with.” These were hard lessons to learn, but they remain true today especially when it comes to disability claims,

Disability insureds and claimants come with all sorts of different personalities including those who think that the more they OVERSPEAK their claims, the more payable they are. Actually, it’s quite the opposite. Writing ten pages about your disability over and over again has a surprising effect most claimants wouldn’t even consider. That is, excessive writing and written subjective description gives claimants and insureds WORK CAPACITY.

Let’s take for example a female claimant who was an Executive Secretary. She is now claiming disability on the basis that she cannot sit for long periods, and can no longer do repetitive keyboarding. Yet, her insurance company continues to receive long reports from her expounding on her disability and how it affects her. Other claimants often call the insurance company and carry on long conversations about themselves and their disability.

I think it is important for all insureds to remember that, “insurance companies cannot hold against you what you do not say.” In fact, this is one of the major recommendations I make to my clients. Another is, “answer the insured’s questions, then STOP.” It is important for all claimants and insureds to remember:

  • Insurance companies consider claimants and insureds to be the least credible. What you say doesn’t matter.
  • Insurance companies do not care about how you “feel”, or how your disability is affecting you. Leave out all of your subjective comments about your health and disability.
  • Do not send any insurance company letters with more than two paragraphs. There may be exceptions to this, but only under the guidance of an expert or attorney.
  • Answer only the questions you’ve been asked, then STOP.

Never communicate specific functional capacity since your activities will be used as a basis for surveillance. Remember, less is more. Responses should be the truth, but generic in nature. For example, all insurance companies have a version of the question: “Describe a typical day for you.” Most insureds will give the obvious response and begin with “I have my orange juice in the morning,” and after two pages of described daily activity, “I go to bed after the news.” Wrong, wrong, wrong. The best response is: “My daily activities continually change in accordance with varying levels of pain (or, whatever applies to you) and confusion.” While this is a truthful answer, it does not give specific detail about activity.(See my previous posts on how insurance companies determine work capacity by using METS.)

My message here is that as a claimant who is continually being investigated in order to receive benefits, know what to say, how to say it, and know when to STOP talking. I’ve labeled this tendency as OVERSPEAKING your claim. OVERSPEAKING a claim may indicate to the insurance company that you have work capacity. If you send long letters often, eventually they wind up in the trash as no one is willing to keep reading them. Answer only the questions asked and then, as my attorneys always said, “just SHUT-UP!”