Disability Insurance and the Dentist: Can You Collect on Your Disability Insurance Policy?

You have worked as a dentist for your entire career.  Your family relies on you, and you have numerous financial obligations both at the office and at home.  The stress associated with a disability can cause you significant problems, including, for example, the financial requirement that you contribute toward business overhead even when you are not raising revenue.  In order to protect yourself in case of total or partial disability, you have purchased disability insurance.

Unfortunately, you suffer an injury or become so ill that you cannot continue your career, and you then file a disability claim with your insurance agent.  Naturally, you expect it to be approved.  Instead, shortly thereafter, you are contacted by an insurance adjuster, not your agent.  Unlike your agent, the insurance adjuster is hostile; the questions that he asks suggest that you are malingering and have submitted a fraudulent claim.  You attempt to be cooperative, providing the insurance adjuster with the additional information he requests, but your claim is again denied.  To add insult to injury, you learn from the adjuster that the insurance company has conducted clandestine surveillance of you and videotaped your activities and, based on the tapes, believes that you are not disabled at all.  Dumbfounded by the insurance company’s response, you ask yourself if there is anything that you can do to make the insurance company pay the benefits it promised.  The answer is yes.

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Why Is It So Hard to Collect on My Disability Insurance Policy?

Disability Insurance Article cover

Attorney Ed Comitz’s article, Why Is It So Hard to Collect on My Disability Insurance Policy? Avoiding Mistakes when Filing a Claim, was published by Whitehall Management in its May/June 2010 Newsletter magazine. The article explains why dentists and other healthcare professionals have such a difficult time collecting disability insurance benefits and advises against some common mistakes often made when filing a claim. Read the full article here: Avoiding Mistakes when Filing a Claim

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Unum Profits While Ailing Workers “Gut it Out”

In an interview with Andrew Frey of Bloomberg Businessweek, Unum Group CEO Thomas Watjen said that the economic slump has resulted in fewer disability claims being filed, with workers suffering from lower back pain, nervous conditions and other “more discretionary” conditions more likely to “gut it out” than they would in better economic times.

You can’t make a windfall on these products.  It’s not like you can go on claim and make an enormous amount of money.

While workers are gutting it out, Unum has reported five straight quarterly profit increases.  Read the full article here: http://www.businessweek.com/news/2010-05-25/ailing-workers-gut-it-out-opt-against-disability-update2-.html

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Too Sick to Work? They Disagree

In the February 10, 2010 edition of SmartMoney Magazine, Brad Reagan writes:

Once employees go on disability, critics say, insurers today are more likely to require hour-long chats on the phone, hound patients for medical updates and push them back to work as soon as possible—often clashing with doctors who think the workers need more recovery time.  “These claims are now managed, whereas they used to just be monitored.  It can be very intrusive,” says Terry Smith, a principal in Mercer’s health and benefits practice.

To be sure, the disability battle is complex . . . . In 2004 and 2005, insurer Unum Group agreed to pay $24 million in fines to various state regulators over its handling of disability claims.  In addition, the company agreed to review previously denied claims between 1997 and 2004—and ultimately reversed 42% of them in the patient’s favor.

. . . In 2004 and 2005, insurer Unum Group agreed to pay $24 million in fines to various state regulators over its handling of disability claims.  In addition, the company agreed to review previously denied claims between 1997 and 2004—and ultimately reversed 42% of them in the patient’s favor.

The full article is available here:  Too Sick to Work – They Disagree

Ed Comitz and the disability insurance attorneys at Comitz | Beethe protect the disability insurance benefits of physicians and healthcare professionals nationwide. Our Arizona practice focuses on the cities of Phoenix, Scottsdale, Tucson, Flagstaff and Yuma. We provide disability income claim advice, assistance with filing disability claims, including completion of disability claim forms and representation in disability insurance litigation.

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Colorado Bill Aims to Prevent Unum-like Denials

In an April 1, 2010 article appearing on lawyersandsettlements.com, Gordon Gibb reports:

With an eye towards preventing the kinds of practices once employed by Unum over the years and under a variety of names, including First Unum, Unum Insurance and Unum Provident, the Colorado Senate in early March passed a bill that would prohibit the payments of bonuses or financial incentives by insurance companies to adjusters who deny or delay meritorious claims or medical care.

. . .

The legislation was proposed to protect consumers from past and current practices of insurance companies that put profit over the welfare of their policyholders. A number of documented examples were provided, including the exposure of $18 million in bonus payments by Unum to insurance adjusters to deny long-term disability and various other claims.

It was reported that Senate Republicans refused to support the legislation, claiming that the bill was unnecessary and that no evidence demonstrative of such practices existed. This, in spite of a widely distributed report from “60 Minutes,” the investigative unit of CBS that provided stunning evidence of such practices.

In a broadcast aired November 17, 2002 the late Ed Bradley conducted interviews with a number of adjusters who worked for Unum Provident. They all stated unequivocally that adjusters were offered financial incentives to close claims.

UPDATE MAY 17, 2010:   Colorado Governor Bill Ritter signed Senate Bill 76 into law.  The bill’s sponsors, Sen. Carroll and Rep. Primavera are quoted in the Governor’s Press Release as follows:

“Wrongful denials and delays of medical claims have been the top complaints against insurance companies for five years running,” Sen. Morgan Carroll said. “Senate Bill 76 protects consumers from insurance companies actually paying financial incentives to encourage denial of those claims and prohibits companies from putting profits over people’s health.”

“The only thing worse than being sick and having your health care coverage canceled, is the idea that some claims-employee on the other end of a phone was given a bonus to make that decision,” said Rep. Primavera.  “This bill is so obviously the moral and right thing to do.”

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Once ERISA, Always ERISA: How and why to avoid having your disability insurance policy sucked into the black hole of ERISA

Disability insurance carriers have increasingly used The Employee Retirement Income Security Act of 1974 (ERISA) to their advantage.  While ERISA was supposed to be for the protection of employees, it is actually being used to protect insurance companies and employers.  ERISA leaves insurance policyholders little leeway, because it preempts more stringent state insurance laws and allows insurance companies to insert language into the policies they issue that makes it easier to deny claims.  Despite these disadvantages, the policyholder is not necessarily doomed to fail provided that he or she takes appropriate measures before filing suit – often, consulting with an attorney before filing a claim can substantially increase the odds of receiving benefits.  It is important to understand your policy now, so as to prevent the double disaster of incurring a disability and not being able to recover the benefits that you deserve.

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Comitz | Beethe: Proud in its Continuing Support of the Western Regional Dental Convention

Ed Comitz and Phoenix-based Comitz | Beethe were pleased to show our continuing support for the Arizona dental community by participating in this year’s Western Regional Dental Convention held in Phoenix, Arizona.  Dentists, orthodontists, oral surgeons, pediatric dentists, endodontists, periodontists, prosthodontists, oral pathologists,  dental hygienists, dental practice administrators and others gathered at Arizona Convention Center for two-and-half days of continuing education. Attorney Ed Comitz’s topic at the Convention was “Disability Insurance Litigation and the Disabled Dentist,” which has been written on extensively in Inscriptions.

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Federal Court Affidavit of Former Unum Employee

A sworn affidavit by a former UnumProvident employee in a 2004 case in the United States District Court for the District of Maine (Case No. 2:2004cv-00001) provides interesting insight into some of the tactics used by Unum.   Daniel Donatelli’s affidavit appears below.

UNITED STATES DISTRICT COURT
DISTRICT OF MAINE

Daniel Donatelli, Plaintiff vs. UNUMPROVIDENT CORP., Defendant
Civil No. 04-1-P-S

AFFIDAVIT OF DANIEL DONATELLI

NOW COMES Daniel Donatelli and hereby states as follows under oath:

  1. My name is Daniel Donatelli. I am 18 years of age or older and believe in the obligation of an oath. The facts stated below in this affidavit are based on my personal knowledge.
  2. I was hired by Unum as a Disability Benefit Specialist to process long term disability claims. Disability Benefit Specialists at Unum had authority to make decisions on claims.
  3. After Unum’s merger with Provident, I became a customer care specialist and later was transferred to the Cardiac Psych Unit. Customer Care Specialists at UnumProvident did not have authority to make decisions on claims including approval, denial, and settlement. Our role became primarily processing and not managing.
  4. I did not begin working in the Cancer Unit until after February 25, 2002.
  5. While working in the cancer unit, Dennis Hersom told me that I would not survive a performance management program regardless of any improvement that I made with my work performance. Therefore, I resigned.
  6. While working in the Cardiac Unit and the Cancer Unit, I had some ethical and moral concerns regarding claims not being paid properly due to the pressure to meet quotas for closing claims.
  7. While I was at Unum, Unum provided insurance policies for employee sponsored plans, union or employee organization sponsored plans, employer sponsored plans, church plans, government plans, and many individual disability policy contracts.
  8. There was at least one individual Customer Care Specialist in my Cardiac Psych Unit, as well as an individual in my Cancer Unit, that was responsible for handling claims under individual disability insurance policies issued by Unum.
  9. I understood that all of these policies were subject to the same claims handling process and procedures. When I expressed concern about how the claims were handled, I was expressing concern for all claims and not just those on my caseload.
  10. I personally handled processed claims under church plans (for example, priests) and government/school plans (for example, teachers).
  11. Advance pay and closure was a way of closing claims based on a hypothetical ramp up of hours that was established by a customer care specialist or a vocational rehabilitation consultant. It was also based on an opinion from a UnumProvident doctor who made a determination of what the claimant was capable of doing. I believe that the advance pay and closure procedure is illegal because it could result in a claimant being subjected to higher scrutiny by UnumProvident if the claimant reopened his or her claim for benefits after a period of advancement has lapsed. Because the claimant had no right of appeal, and the claimant was not notified in advance, the claimant would be subject to higher scrutiny thereby misleading the client into agreeing to take an advance pay and close.
  12. The advance pay and close was regularly misused as a profit technique for Unum to free up reserves attached to each claim. For example, if we were running behind on projections to meet quotas for the month, we would be required to go back and look up part-time people that we could either close out through denial or through advance pay and close. Although advance pay and close was supposed to be with insured consent, often we were required to pressure them over and over again to accept an advance pay and close. Usually using advance pay and close had the effect of literally badgering an insured to go back to work. We were basically instructed to tell the insured that we expected them to be back to work in 30 days, “here’s your check.” Often, we would be required to apply this pressure even if the insured did not feel they were ready or able to return to work full-time. Rather we were required to use Unum medical staff to push the issue.
  13. I believed and reported to my supervisor that I thought the Defendant was misrepresenting policies and plan benefits to airline pilots and truck drivers in order to sell them policies. These people were lead to believe that the policies would cover them if a health condition made them unable to do their job, including maintenance of their license. However, the actual policies sold by Defendant included provisions that denied benefits if Unum doctors determined that the insured was physically able to perform the job requirements- even if those people were unable to get medical clearance from the FAA or state and federal licensing agencies to reinstate their license. I believed these activities were in violation of state and federal regulations.
  14. I also reported to my supervisors that Defendant participated in and engaged in phony round table discussions as a way to put on a show for potential customers that were receiving guided tours of the Unum Provident building. I believe this practice to be misrepresentation in order to sell policies, when, in fact, the round table discussions were faked and did not represent what the actual round table discussions were like. Actual round table discussions were geared toward speeding up resolution and closure of a claim. Phony round table discussions were meant to leave the potential customers to believe Defendant engaged in intelligent and objective round table discussions with regard to each claims. Not all claims went to roundtable.
  15. I was, at times, asked to miscode claims or to manipulate the time a claim was coded in order to manipulate reserves. I was asked to do this by Cynthia Bellefountaine, Dennis Hersom, and on occasion, Steve Leask.
  16. Cynthia Bellefountaine and Dennis Hersom, my managers, told me that the miscoding or manipulation of the time frame of coding a claim would have a direct impact on our reserves.
  17. I was pressured to close claims to meet quotas. The pressure would include claims denials based on the wording of medical information being changed. This change could result in an immediate denial of a claim. I believe that the rush to deny a claim by changing medical information was an improper handling of a claim.
  18. I felt pressure to close a claim by coding improperly. I was instructed to do this by my superiors. I believe this to be an improper or fraudulent practice with regard to handling claims.
  19. I was never notified by Unum or UnumProvident that I maintained any type of fiduciary status with regard to contracts or policies at Unum that were subject to ERISA. I was not a plan participant or beneficiary with regard to any of the complaints to which I complained.
  20. I resigned my employment at UnumProvident, in essence, in lieu of being fired. I was told by my supervisor that I would basically be given a 60-day performance management program or to resign. He made clear that I would not survive a performance management program regardless of any attempts I made, or improvement of my numbers. Mr. Hersom warned me that “I will not be able to give you a positive reference. You do not want a bad evaluation in your file.”
  21. I was concerned that claims are not being paid appropriately, as a result of the pressure to close claims in the Cancer Unit. Whether or not an individual claimant met the elimination, must be decided by interpreting the terms of the “contract.” Since UnumProvident handled individual disability contracts, as well as group plans, sometimes the elimination period would have to be decided by interpreting the terms of an individual contract.
  22. Some doctors and nurses had policies administered and/or sold through UnumProvident that provided benefits to them if they could not work on their own occupation. I understood that certain categories of nurses and doctors, such as emergency room personnel, worked in a very specialized and niche field within the industry. I based this conclusion on information provided by the insured’s. Also based on occupational descriptions provided by the employers and nurses/doctors, I understood that an emergency room nurse who was medically disabled from working in that occupation, would likely not have the training and transferable skills and qualifications to work outside of such a position, such as in an office environment or a consultant environment. However, Unum would deny these claimants benefits if Unum determined that they perform a less strenuous nursing position, even if they were not qualified for the position and had no chance of ever obtaining such a position.
  23. Often we were behind schedule in meeting our team quota for claim closures, the consultants and managers would pressure us to find other additional claims to close. One pressure to deny claims had to do with the wording in medical reviews. Often we would be asked to have the wording in medical reviews manipulated so that a denial could be made immediately. This caused us to rush and deny a claim before medical information was actually sufficient to make a good faith determination.
  24. Another tactic that Unum took when our team was falling behind in out quota, was to send us back and go through all files for a sort of “round up,” looking for loopholes or technicalities in the contracts or anything else that would help close the claim. Sometimes they would set aside a Saturday, requiring all Customer Care Specialists to come in and do a sort of “round up” for claim closures. I believed these tactics would result in some claims being closed prematurely.
  25. I filed a complaint against UnumProvident for whistle blowing before the Maine Human Rights Commission. I did not make any request for damages with regard to that complaint.
  26. Approximately a month before Hersom approached me to tell me that my job was on the line, I received my annual performance appraisal. Although the performance appraisal had some coaching comments, the performance appraisal reviewed my performance for the year as consistently meeting all goals and standards.
  27. I had no connections with the state of New York. During the relevant time frame, I never went to the state of New York. My deposition was taken here in Maine, my employment took place all here in Maine, and my entire relationship with Defendant took place here in Maine. I received, and read in Maine, a copy of the letter sent by Mr. White on November 6, 2002 to Mr. Gelber. I was embarrassed and humiliated by the false tone and nature of the letter.
  28. I requested, through counsel, that Unum retract the letter that it sent to CBS News, but Unum refused.

Dated: 9/17/2004

STATE OF MAINE
KENNEBEC, S.S. Dated:
9/17/04
Personally appeared the above-named Daniel Donatelli and swore to the truth of the foregoing statements to the best of his knowledge and belief.

The disability insurance attorneys at Comitz | Beethe provide legal representation to protect the disability benefits of medical and dental professionals nationwide and throughout metropolitan Phoenix, Scottsdale, Tucson, Flagstaff and Yuma. We provide disability income claim advice, assistance with filing disability claims, including completion of disability claim forms and representation in disability insurance litigation.

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Unum’s Profitability May Be Illusory in Light of Reserve Cuts, According to Barron’s

Disability insurer Unum has increased profits by trimming an account that reserves against future claims.  According to Barron’s, because Unum was wracked with scandal and unprofitability over the last decade, largely due to its administration of poorly underwritten and priced policies sold to professionals. By cutting reserves, Unum added $292 million to 2007’s $1.1 billion pretax earnings, and $138 million to $1.3 billion pretax earnings in 2008, according to Barron’s.  Barron’s cautions against investors about potentially illusory earnings growth, especially since Unum has a history of “alarming setbacks.”

The full article can be read here:  Unum – An Accounting Disability

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ABC News: Man With MS Fights for Long-Term Disability Insurance

Good Morning America recently featured a story about an accountant from Florida, Chris Tucker, who had been diagnosed with Multiple Sclerosis by 11 doctors, having difficulty collecting his long-term disability insurance benefits from Standard Insurance Company because Standard’s doctor – who had never even met Mr. Tucker — did not believe there was sufficient evidence to support the MS diagnosis.

Chris Cuomo of Good Morning America investigates the story, and the issues surrounding doctors on insurance company payrolls, in the video below.  An ABC News story can also be read by clicking here:  GMA – Man with MS Fights for Long-Term Disability Insurance

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