Health Administration Responsibility Project

Top Unconscionable Practices Insurers' and HMOs' Use To Deny Claims

     Linda Nee, the UNUM whistleblower, has listed the top five unconscionable claims practices used by disability insurers to deny claims. And they're used every bit as much by Health Insurers and HMOs.

Forewarned is forearmed!

    ♦ 1. Use of the "objective evidence standard" when there is no contractual policy language requiring or allowing it. 99% of group LTD polices do NOT require objective evidence as proof of claim. Whenever an insurance company starts talking about lack of objective evidence, call them on it.

    ♦ 2. Denying claims under the 12 or 24 month mental and nervous provision for impairments which are NOT listed of the DSM-IV, the standard list of mental and nervous conditions. They claim that Lyme disease is a made-up impairment, fibromyalgia is all in your head, "you only have a somataform disorder", etc. Well folks, physical impairments such as Lyme, MS, RSD, Lupus, and CFS are not mental disorders and are not listed in the DSM-IV.

    ♦ 3. Breach of contract. This encompasses a whole list of actual claims practices but if the company applies interpretations of policy provisions or applies internal standards for which there is no provision in the contract, then it's a breach of contract. If the company advertises and promises to pay under certain conditions and then doesn't, well, then it's a breach of contract.

    ♦ 4. Abuse of discretion (ERISA) or "bad faith" (IDI). If a disability insurer willfully and deliberately, with intent to harm the claimant, devises internal strategies to deny claims. A top example is UNUM's direction to all internal personnel to ignore any medical documentation or restrictions coming from insureds' physicians and to rely only on opinions of its own hired physicans.

    ♦ 5. Targeting claims for denial. Many disabiity insurers target claims for denial by impairment, class, group, age, number of months of paid benefits, and financial reserve. If you fall into any of the "target" groups, most likely the claim will be denied.

And 'Dave61599' has added 7 more, from the viewpoint of an insured:

    ♦ 6. Using a definition of disability that is not in the policy to deny the claim. " You do not meet the definition of total disability", when the policy had an "own occupation" definition for two years and "any occupation" definition after two years. At no place in the policy was there a total disability definition. [Or, in California, using a definition in the policy which has been explicitly rejected by the courts.]

    ♦ 7. Removing the most damaging documentation from the claims file before sending it on for further processing. This includes not sending the complete claims file to the claimant when requested.

    ♦ 8. Saying, in the denial letter, that they reviewed the submitted documents, while actually ignoring everything that was in them and not addressing any of the concerns that they brought up. It is just like someone who keeps telling a lie and ignoring the truth in hopes that if anyone other than the claimant looks at the documentation, only the insurance companies letter will be looked at.

    ♦ 9. Sending out requested information late, so there is not time to make correction and additions to the claims file based on what they sent to you. I was in the position where my claims file came after the date on my denial letter.

    ♦ 10. Training claims personnel to misinterpret the medical information, while requiring the persons qualified to review medical file to water down their comments to make it easier to deny the claim.

    ♦ 11. Having sales material that make claims about coverage that is way different than what their training teaches claims handlers that the policy covers.

    ♦ 12. Having someone edit the Doctor's report before bringing it to be signed or even forging the signature.

AND: The Top Five Mistakes Insureds Make

    ♦ 1. Talk too much. Answer all questions asked truthfully, but do not volunteer additional information about your life. Do not write extensive letters, or any letters to a disability insurer more than a few sentences. Defer all questions about restrictions and limitations to your physician and all questions about your occupation to your employer. Answer all questions asked truthfully, then be quiet. A disability insurer cannot hold against you what YOU DO NOT SAY.

    ♦ 2. Failure to read the policy. Failure to meet deadlines. Anyone or thing that controls your money also controls you and the quality of life for your family. Obtain a copy of your policy well in advance of a disability and know what you are entitled to long before as sudden and unexpected impairment occurs.

    ♦ 3. Failure to discuss claim candidly with treating physicians. A disability claim should always be discussed with all treating physicians. You and your physician should decide how to handle frequent and repeated requests for information, IME's and surveillance.
Physicians aren't always willing to support disability when faced with vexatious requests from an insurance company. Talk about it in advance, make sure your physician is well aware of the disability claim. Ask physicians to notify you of all requests they receive from the disability insurer.

    ♦ 4. Failure to stay in control of the claim. Maintain a journal of everyone you speak to including names, dates and topic. Obtain all medical information yourself and submit to the insurer confirmation of receipt. Never fax without a printed confirmation of fax receipt. Ask questions, take names. Find out who is really making the claims decisions, get supervisor names, and/or ask to speak to supervisors. Be polite, but stay in control of the claim. Enforce deadlines.

    ♦ 5. Failure to realize the disability insurer is not acting in your best interests.
Insurance companies make money by NOT paying claims. This is the entire concept behind insurance "risk". Never believe a disabilty insurer is acting your best interests. Understand the intent and motivation of any disability insurer and act accordingly.

Insurer Stall Tactics

    ♦ 1. Demand "More Information". To stall the actual delivery of care, insurers hold out an insincere promise to authorize payment if the doctor provides more information. This leads the doctor on indefinitely, while insurers never say absolutely "no" until the patient gives up or dies. Doctors agonize over having to choose whether to wait one more day for approval or to go ahead with the surgery and potentially damn the patient, his family, and the institution, to assuming the financial consequences. If they do go ahead without approval, no one rescues the bankrupted families.

    ♦ 2. Call a procedure "Experimental". Insurance contracts don't give the criteria for such a designation, but insurers still claim the right to define what is experimental. Such unilateral decision-making means the insurer is party to an unsustainable contract contracts should bestows rights and obligations on each party, and shouldn't include undefined terms.
A procedure shouldn't be considered experimental if the statistical outcome is known, or if consent is not required by the Institutional Review Board, or if others have already reported the procedure.

    ♦ 3. The "Expert" review. An expert is a doctor who did a procedure or took care of a similar patient this week. Insurers define any has-been, retired, unemployed failure with a medical license an expert, paid to deny care. This is practicing medicine without examining the patient or seeing all the data. In effect, the licensed nurse or doctor working for an insurer is practicing medicine unprofessionally and criminally.

from a letter by Giuseppe Del Priore M.D.
Los Angeles Times, 1/3/2008