Finally, Larry West of West Financial Consulting Inc. in Huntsville, Ala., cites the case of a friend who experienced what he terms "sudden death." "Her heart stopped and had to be shocked back six times before reaching the hospital. She was a teacher, and the school system put her on disability retirement. The documentation I developed for [a claim against her large disability insurer] was also sent to the Social Security Administration, which approved her for full disability benefits on the first application. But that meant nothing to her insurer. It took me eight months to negotiate a deal with them. Meanwhile, friends gave her money to live on. My friend had to sign a waiver preventing her and me from talking about the cases," says West.
Why is it agents and advisors cite such different experiences? That's hard to say, although Natovitz offers an opinion: "I think that advisors may not have the full story. It's not unusual for a claim to be denied initially because the client has not provided the insurance company with all the information requested. The company denies the claim, closes the file and reopens it once the client has provided what's required," Natovitz says.
So perhaps advisors don't have as much claim information as agents who, in turn, probably have less insight into the process than Fred Fox, C.R.C., C.D.M.S., C.V.E. (www.ltddisabilityexpert.com) of Austin, Texas. Those initials stand for Certified Rehabilitation Counselor, Certified Disability Management Specialist, and Certified Vocational Evaluator, and they add to Fox's already-impressive record of work experience. He's spent the last 20 years as a consultant representing all parties involved in the claim process- claimants, plaintiff's lawyers and DI companies-and is presently a consultant on a case that has gone from UNUM claims interaction to active lawsuit. He describes his service as "assessing the abilities and disabilities of claimants who have had their claims denied or payments terminated."
Himself a policyholder with UNUM, Fox says his own evaluations of large DI carrier claim processes in the 1980s convinced him they didn't pay a lot of attention to the claim details, most didn't have required rehabilitation clauses, and they didn't discriminate among claims; for the most part, they just paid them. However, he says, that changed several years ago. "In early 2001, I was called in on a number of cases involving UNUM, Provident, Paul Revere and other carriers, and I was starting to see what appeared to be a wholesale delay or denial orientation."
After a lot of contact with the UNUM adjuster system, Fox says, by the end of 2001, "it became clear they were no longer the same company. I was concerned that most of the people I dealt with on high-dollar claim evaluations had zero training in vocational evaluations or rehabilitation, and didn't have any particular educational credentials. Most also had very little experience with assessment of disability-related medical conditions prior to their starting work as claims adjusters. They had internal policy training, but when I would talk to them about medical documentation as it relates to occupational issues, I was nearly always instructed to state my concerns in writing because they needed to review them with others in-house."
Fox concludes that the big DI carriers now place obstacles in the way of the payment process in order to hold onto money longer. "It appears to me there's now an institutionalized delay in paying LTD claims in that the claims department isn't provided with sufficient medical records to enable them to begin payment when the elimination period is up. So, whereas we were seeing 30- to 90-day delays in the 1980s, payments now take much longer to begin. The companies make retroactive payments, of course, but there's no requirement that they pay a penalty or interest."
Another problem for the claimant, asserts Fox, is the frequent evaluations now required by DI companies. "What they're doing now is requiring LTD recipients to submit monthly certification of disability. The claimants' physicians have usually done a lot of diagnostic work, they feel badly their patients seeking claims haven't recovered, so they comply with these evaluation requests-at first. After six months or so, the physicians start to get annoyed at being asked for the same stuff every month, and the insurers often won't pay that month's benefit if the physician's form isn't completely filled out. The patients don't want to upset their doctors and risk being terminated by them, so they don't press them for this information," Fox adds. On top of all that, he says, the patients need treatment and aren't getting the benefits they need to pay for it.
Where you stand depends partly on where you sit. Not surprisingly, UNUM takes issue with its detractors' characterizations. Ralph Mohney, senior vice president of UnumProvident's Return to Work Services-Development department, says, "UnumProvident's claim process includes numerous safeguards to ensure thorough, fair and objective evaluation of all claims. It begins with extensive training on our process, including our commitment to pay all valid claims. Extensive clinical resources are available to assist in the evaluation of medical information and in developing return-to-work plans. Any determination that a claim is not payable requires review and second-level sign-off by a senior technical expert. We employ approximately 100 physicians and 350 nurse case managers and vocational rehabilitation specialists who apply focused expertise to specific types of claims."
As for delays, Mohney says, "There is absolutely no practice of delaying payments to our claimants. We have defined service standards that we share with our customers at the time they file a claim, specifically outlining our responsibility to provide them with timely and fair evaluation."
In defense of allegations that claims processors are ill-prepared, Mohney describes a process by which new hires destined to administer individual disability claims go through a ten-week training program, followed by their handling of a reduced caseload under mentor supervision. After eight weeks on the job, they are brought back together for two weeks of "refresher" training and are given the opportunity to ask questions based upon their actual claim-handling experiences. Following these three stages, they gradually increase their caseload to a full level.