Source: https://www.disabilitycounsel.net/publications/disability-blog/
Timestamp: 2019-04-20 14:40:39+00:00

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In this post, we’ll be looking at the common mistake of not being actively engaged in the process of selecting your disability insurance coverage.
This is problematic because there are no standard policies, and the differences between the multiple key provisions in policies are difficult to explain—even for an agent. Therefore, asking for the “same” coverage is often a request that is impossible for the agent to achieve. Additionally, while input from an agent can be helpful, insurance companies rarely provide agents with adequate training or information about a policy beyond what is necessary to sell it. As a result, agents are often unfamiliar with many of the complex terms in a policy, and the agent may not know how certain key provisions will play out during the claims process (which is understandable, as they typically just sell the policies and do not have legal experience filing claims or litigating these matters).
In this post, we’ll be looking at the common mistake of failing to carefully review your policy application.
Action Step: Rather than completing the policy application in your agent’s office, take the application home with you so that you can carefully complete, review, and sign it on your own. Then keep a copy of your application in an organized file, so you have a record of the answers you provided.
What is the Effective Date of My Disability Policy?
The “effective date” of a policy is the day your policy becomes enforceable. While this may seem like a simple concept, it is not always as straightforward as you might think. Understanding the date your policy became effective may require you to read several different provisions together. Additionally, if you apply for benefit increases at a later date to increase your policy’s monthly benefit, this can further complicate matters because, depending on the terms of your policy, you can end up with multiple effective dates for the same policy (corresponding to each benefit increase to the base amount).
EFFECTIVE – Coverage is Effective when this Policy is issued and delivered to You provided the first full premium is then paid and all answers on the application are true and complete as if made at the time of delivery.
Coverage is Effective on the Issue Date if a premium was paid at the time of the application; the Conditional Advance Premium Receipt was given at that time; and this Policy was issued at standard rates exactly as applied for.
Additional coverages are Effective on the Monthly Anniversary on or after the date We issue the new Policy Specifications containing the coverage, subject to payment at the initial premium. If the initial premium is not paid when due, the coverage will be treated as never having been Effective and new Policy specifications will be issued showing this fact.
Under this provision, there are three possible effective dates. First, the policy’s coverage will be effective when the policy is issued and delivered, as long as the first premium was paid and the application was accurate when it was submitted.
ISSUE DATE – The date the Policy Specifications are printed. Subsequent Policy Specifications carry their own Issue Dates.
MONTHLY ANNIVERSARY – [This date is] computed from the Policy Date shown in the Policy Specifications…. The Monthly Anniversary is the same date in each succeeding month as the Policy Date.
So, as you can see, under some policies, determining when your coverage becomes effective (and/or whether benefit increases apply to your claim) can be particularly complicated and depend on the particular facts at play. Disability insurance policies—particularly newer disability policies—are complex documents, and insurers often take advantage of this complexity when denying claims. If you are having difficulty understanding your policy’s provisions, an experienced disability insurance attorney can help you interpret confusing policy language and apply it to your particular situation.
Unum, originally called Union Mutual, was founded in 1848. Over the years, Unum has merged with additional companies such as Colonial Life and Provident (which had acquired Paul Revere) to form one of the largest insurance companies in America. In 2017, Unum’s total revenue reached $11.3 billion, with total assets of $64 billion.
In 2004, Unum was the subject of a multistate market conduct examination which identified the following inappropriate claims handling practices: (1) excessive reliance on in-house medical staff; (2) unfair evaluation of attending medical examiner notes; (3) failure to evaluate the totality of the claimant’s medical condition; and (4) an inappropriate burden placed on the claimants to justify eligibility for benefits. Following the 2004 investigation, Unum was required to reform its claims practices and pay a fine of $15 million. Unum was also required to reassess certain denied claims stretching over a seven year period. It is estimated that compliance with the settlement cost Unum around $120 million.
If you are a dentist or physician with a Unum policy and are thinking about filing a disability claim, you should be prepared for an in-depth evaluation of your occupational duties. When a disability claim is filed by a professional, the amount of money at stake is significant. One way for the companies to save money is to deny the claim. Another is to maintain that the claim is not a “total disability” claim, but rather a “residual disability” claim, so they only have to pay a fraction of the full monthly benefit amount.
Whether a claim is a “total” or “residual” disability claim often come down to how the duties of your pre-disability occupation are defined in the context of your claim. Then, the insurer assesses whether it can argue that you can still perform any of those duties, taking into account what your medical records report regarding your limitations and any post-disability job or volunteer activities you may be engaging in. Even if your policy allows you to work in another occupation and still collect benefits, the insurance company may argue that your new job has overlapping job duties with your prior occupation, and therefore you are only partially disabled.
For example, in Ogborne v. Unum, a dentist filed a disability claim with Unum after suffering a ligament injury to his right index finger. His doctors told him that his injury would be slow healing, and eventually told him that his injury was permanent. Unum denied his claim, stating that he had given untimely notice of the claim and that the dentist was not “totally disabled” because his particular injury only prevented him from performing “two types of procedures.” Unum also relied on the fact that the dentist had returned to work and was making more money than he had before the injury.
The dentist sued to challenge the denial, and the court determined that Unum was improperly interpreting the definition of “total disability” under the policy, which defined “total disability” as “the inability of the Insured to perform the duties of his regular occupation.” The court observed that “[t]his definition is susceptible to two different, yet reasonable, interpretations: namely, that the insured is totally disabled if he cannot perform either more than one of his pre-injury duties or all such duties.” Then the court determined that the ambiguous language should be construed against Unum, as the drafter of the contract.
Next, the court determined that the dentist had, in fact, produced evidence demonstrating that he was unable to perform several of the duties of dentistry, including root canals, periodontal work, and root scaling. Ultimately, the court ordered Unum to overturn the denial, but it took several years and a favorable decision from a judge to get Unum to pay benefits.
These are just a few examples of things to be aware of if you have a Unum policy or claim with Unum. Unum policies are not all identical, and they are updated frequently. Your policy may or may not include the provisions mentioned above. If you are considering filing a disability claim, you should consult with an experienced disability insurance attorney to learn more about your policy and any potential issues related to your particular claim.
 Ogborne v. UNUM Life Ins. Co. of Am., No. 3:04CV7231, 2006 WL 2505905, at *2 (N.D. Ohio Aug. 28, 2006).
 It should be noted that this particular case was also decided under Ohio law. As the law regarding how disability policies are interpreted varies from state to state, this case could have come out differently in a different jurisdiction.
Standard Insurance Company (also branded as “The Standard”) is one of the largest disability insurance companies in operation, with over $4.3 billion collected annually from premiums.
If you have a Standard policy, you will want to pay close attention to how disability is defined under the policy, as Standard policies can contain provisions that shift from “own occupation” coverage to “any occupation” coverage after a certain period of time. Because of this, Standard will sometimes approve a claim initially, but then reassess and terminate the claim when the more stringent “any occupation” provisions kicks-in later on.
For example, in Pringle v. Standard Insurance Company, Standard initially found the claimant to be disabled due to bilateral shoulder pain, bilateral knee pain, and numbness in his legs, feet and toes. Later on, after the “any occupation” definition replaced the “own occupation” definition of disability, Standard terminated the claim (and subsequently denied the claimant’s appeal of the claim termination) even though the claimant’s treating physicians had all opined that he could not work.
In support of its termination decision in Pringle, Standard relied on memos produced by its physician consultants after file reviews of the medical records. Notably, while other companies often only have one doctor conduct a file review of the record when evaluating whether to deny a claim, Standard in this case paid three doctors of various specialties to review the record and author peer review reports. Accordingly, if you have a Standard policy, it is important that you have supportive doctors and accurate and up-to-date medical records that support your claim, because you may have to go up against multiple physician reports if your claim is denied.
Another tool that Standard uses is the peer-to-peer call, where it assigns a doctor to contact your treating physicians to discuss your claim. This can be problematic, because the doctors hired by Standard (and other insurers) are often adept at asking trick questions, and don’t always explain the significance of how key terms like “own occupation” or “total disability” are defined in your particular claim. After the call, the insurance company’s doctor will typically prepare a letter “summarizing” the call in a way that favors the insurance company, in the hopes that your doctor (who is likely very busy) signs off on it without reading it carefully.
In the Pringle case, mentioned above, Standard’s doctor conducted this sort of call and the follow-up letter to the primary care doctor stated, in part, “you indicated the claimant was a ‘muscular guy’ and that, from your perspective, the claimant could function at a sedentary capacity as people in wheelchairs and who have had amputations are capable of working at a sedentary capacity.” According to the case record, the primary care doctor ended up signing off on this statement, even though it is arguably inconsistent with what the primary care doctor stated in his prior records and opinions (raising the question of whether he, in fact, read it before signing and sending it back to Standard). Ultimately, in Pringle, the court reversed the termination and required Standard to pay back benefits, but it took several years of costly litigation in order to get the denial reversed and the benefits reinstated.
These are just a few examples of things to be aware of if you have a Standard policy or claim with Standard. Standard policies are not all identical, and they are updated frequently. Your policy may or may not include the provisions mentioned above. If you are considering filing a disability claim, you should consult with an experienced disability insurance attorney to learn more about your policy and any potential issues related to your particular claim.
 See, e.g., Pringle v. Standard Ins. Co., No. 3:18-CV-05025-RBL, 2019 WL 912297 (W.D. Wash. Feb. 25, 2019).
In previous posts, we have discussed why it is important for professionals to be actively engaged in choosing their disability policies. While agents can provide helpful advice, it is ultimately your financial well-being on the line, and ultimately up to you to review your policy, become familiar with the provisions of the policy, and confirm that you are paying for the coverage that you expected to receive.
The case of Jacobs v. Chadbourne illustrates the importance of reading your policy. In Jacobs v. Chadbourne, Gene Jacobs purchased disability insurance from Unum through the services of an independent broker. Two years later in 1988, Jacobs asked his broker about adding lifetime coverage to his policy, and Unum issued Jacobs a “Lifetime Total Disability Benefit Rider.” This rider stated that Unum would pay benefits if Jacobs’ disability begins before age 65 and continues until age 65. However, Jacobs was reportedly unaware at the time that this rider also stated that his maximum monthly insurance benefit would decrease 10% for each year after age 55 and until age 65.
In 2003, Jacobs called Unum to confirm his benefits in his disability policy. Unum faxed a letter outlining Jacobs’ benefits, which provided the policy’s issue date, the monthly premium, and the maximum monthly benefit. Notably, this letter did not mention the lifetime rider or the 10% reductions described in that rider.
In 2011, Jacobs submitted a claim for total disability benefits based on a date of disability at age 64. Unum accepted his claim and began paying benefits to him, which were subsequently reduced because of the restrictions in the lifetime rider. Jacobs sued Unum and his broker (Chadbourne) for their failure to mention the lifetime rider’s restrictions in the 2003 letter, and argued that he should be entitled to 100% of the benefit amount because he didn’t know about the percentage reductions outlined in the rider.
The Court held that, because Jacobs had the policy and lifetime rider in his possession, he was responsible for knowing the contents of his policy. The Court also found that Unum and Chadbourne had not misrepresented his coverage amounts or otherwise perpetrated fraud or injustice in the 2003 letter. Even though his broker had failed to explain the lifetime rider’s restrictions when Jacobs first purchased the coverage in 1988, and even though Unum had failed to even mention the lifetime rider when Jacobs asked about the benefits in his policy in 2003, the Court determined that Jacobs should not be rewarded for failing to read his policy.
This case highlights the importance of reading your policy and fully understanding its provisions. Oftentimes, marketing materials and policy summary sheets only outline the benefits of the policy, and you have to read the fine print to have a full understanding of the limitations of the policy. If you are considering purchasing a policy, you should not accept coverage or pay premiums for a policy until you have thoroughly reviewed and understand what you are paying for.
 Jacobs v. Chadbourne, No. 17-12868, 2018 WL 2068648 (11th Cir. May 3, 2018).
In this post, we’ll be looking at the common mistake of assuming you have a true “own occupation” policy, when in fact you have one of the new “own occupation” provisions that limit coverage and/or makes it harder for you to collect benefits.
Mutual of Omaha (also known as United of Omaha Life Insurance) was founded in 1909 and is now one of the largest insurance carriers in the United States, with an operating income of $554.8 million and revenues of $8.7 billion in 2017.
If you have a claim with Mutual of Omaha, you may be asked to produce “objective” evidence of your disability. Sometimes, this is an express requirement of the policy. In other instances it is simply a question asked on the claim forms (for example, an attending physician statement). Or sometimes it is question asked in a peer-to-peer call from the insurance company’s doctor to your doctor. Regardless of how it comes up, characterizing a claim as being based on purely “subjective” reports (as opposed to being based on “objective” evidence) is a common tactic that Mutual of Omaha (and other insurance companies) use to deny and terminate claims.
For example, in Schatz v. Mutual of Omaha, a nurse filed a disability claim due to chronic back pain. Notably, at the time she filed for disability, the nurse was working as a medical review nurse for Mutual of Omaha. Nevertheless, Mutual of Omaha denied her claim and refused to pay her benefits under her policy.
In fact, when the nurse sued Mutual of Omaha to challenge the denial, the fact that she worked for Mutual of Omaha ended up hurting her case, to some extent, because the court assumed that Mutual of Omaha understood her particular job duties. Consequently, the court excused Mutual of Omaha’s failure to conduct a detailed inquiry into the physical demands of her position—an omission that otherwise may have proved significant.
Similarly, the physician selected to perform an independent medical exam stated that, although the nurse reported “multiple subjective complaints,” the physical exam was “essentially normal.” In light of these statements, the court ultimately held that Mutual of Omaha’s denial of benefit was proper, under an abuse of discretion standard.
These are just a few examples of things to be aware of if you have a Mutual of Omaha policy or claim with Mutual of Omaha. Mutual of Omaha policies are not all identical, and they are updated frequently. Your policy may or may not include the provisions mentioned above. If you are considering filing a disability claim, you should consult with an experienced disability insurance attorney to learn more about your policy and any potential issues related to your particular claim.
 Schatz v. Mut. of Omaha Ins. Co., 220 F.3d 944 (8th Cir. 2000).
As we have discussed in previous posts, musculoskeletal disorders are common among dentists because the profession requires dentists to perform repetitive movements and hold static positions for long periods of time. Unum, one of the largest private disability insurers in the U.S., recently released the results of a ten-year review of its disability claims, showing that both short and long term disability claims for musculoskeletal issues and joint disorders have increased significantly.
According to Unum’s internal statistics, long term disability claims related to musculoskeletal issues have risen approximately 41% over the past ten years, and long-term disability claims related to joint disorders have risen approximately 24%. In that same period of time, short term disability claims for musculoskeletal issues have increased by 24%, and short-term disability claims for joint disorders have risen 29%.
Unum no longer sells individual disability insurance policies, so the profitability of this block of business is reliant upon premiums received from existing policyholders (or costs saved by denying/terminating claims). Musculoskeletal claims made by physicians, dentists, and other professionals in particular are intensely scrutinized, and often targeted for denial or termination, both because of the increasing number of claims and the difficulty claimants often face in trying to prove up their conditions (which often have primarily subjective symptoms that aren’t often verifiable through a medical exam, or via tests like MRIs or EMGs). In musculoskeletal claims insurers may request that physicians and dentists undergo tests such as independent medical examinations (IME) or functional capacity evaluation (FCE), or the insurer may conduct surveillance in order to find manufacture a basis for denying or terminating a legitimate claim.
Given the rising number claims based on these conditions, Unum and other insurers may subject them to even higher scrutiny. For this reason, physicians, dentists, and other professionals must be aware of the obstacles they can face when filing a claim.
In this post, we’ll be looking at the common mistake of not realizing that you can modify your occupation prior to filing a claim.

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