“Already, Privateer has put some of the roughly $72 million it has raised since its founding toward a 60,000 square-foot growing facility in British Columbia as well as the purchase of Leafly, a Yelp-like website for cannabis reviews and merchant listings.”
Day: 11/18/2014
11/18/2014, ‘Vape’ Is Oxford Dictionaries’ Word Of The Year
http://www.huffingtonpost.com/2014/11/18/vape-word-of-year_n_6178102.html
Vape wasn’t the only substance-based word on the shortlist. Budtender, a word for a server in a “cannabis dispensary or shop,” was also under consideration.
10/24/2014, Judge: No mandate for state to ensure supply for medical pot patients
“A state district judge in Santa Fe said Friday there is nothing in the law that created New Mexico’s Medical Cannabis Program that requires the head of the Health Department to ensure an adequate supply of legally grown marijuana for patients enrolled in the program.”
11/17/2014, These Democrats Could Be The Party’s Ticket To A Comeback
http://www.huffingtonpost.com/2014/11/17/future-democratic-candidates_n_6152346.html
“And New Mexico’s newly elected Attorney General Hector Balderas could succeed popular Gov. Susana Martinez (R) in 2018, when she won’t be able to run again because of term limits. Bernalillo County Clerk Maggie Toulouse Oliver lost a close race for New Mexico Secretary of State but appears to be passionate enough about issues like voting rights to make another attempt for a higher office.”
11/17/2014, The Baffling Math That Determines What People Actually Pay for Obamacare
“In other places, prices (after subsidies) dropped… 10 percent or more in Phoenix and Albuquerque, according to the Kaiser Foundation.”
Letter to Unum 10/24/2014
October 24, 2014
VIA FAX 800-447-2498
Mr. Donald Beaudette
Unum
The Benefits Center
Post Office Box 100158
Columbia, SC 29202-3158
RE: Unum Denial Letter dated 9/12/14
Claimant: Johnna Stahl
Claim No. ***
Policy No. ***
Unum Life Insurance Company of America
Claimant’s Notice of Intent to Appeal
Dear Sir:
HOW I FEEL RIGHT NOW
I hate that I have to spend time out of my painful days to satisfy the needs of Unum. Every time I sit down to work on this letter, while I’m typing away at my computer — with my head, neck, shoulders and back pounding (and pounding) in my ears — I am silently and sincerely wishing that I had to scrub the toilet rather than compose this letter. In fact, right now, my head is pounding so hard in some places, they’ve actually gone tingly and turned numb.
In my last letter, I tell Unum that I am tired of being bullied, and it responds by cutting off my benefits.
INITIAL RESPONSE TO DENIAL LETTER
This Initial Response will notify Unum of my intent to appeal its discontinuance of my long-term disability benefits effective September 11, 2014. (Had to choose 9/11, didn’t you?) The appeal itself will be a more complete response and will follow the Initial Response after I am able to review the Requested Documents (as defined below).
I am prepared to continue in the appeal process until my benefits are reinstated, and hereby reserve the right under ERISA to bring legal action against Unum Group and its subsidiaries, Unum Life Insurance Company of America, Provident Life and Accident Insurance Company, The Paul Revere Life Insurance Company, and persons who evaluate claims for any of those companies (“Unum”), employee benefit plans sponsored by my prior employer and any person providing service to, or insurance benefits on behalf of, such plans, and to anyone who provides services, including the evaluation of claims, related to benefits offered by Unum, my previous employer, or the Social Security Administration.
REQUEST FOR EXTENSION
I am requesting an extension of the appeal deadline, so that I will have adequate time to review the claim file and prepare the appeal. In support of this request, please note the different time-consuming tasks outlined below which I will need to undertake while working on this appeal (including this Initial Response).
UNUM’S DECISION/REASON
“Your Long Term Disability claim has been closed because you have not provided us with the previously requested information within the time frame requested. We are unable to complete our review of your claim.”
My initial claim is that Unum’s continual review of my file suggests an intention to obtain documentation to justify denial of benefits which are properly due under the plan language.
It appears that the only reason my benefits have been discontinued is because there are forms that Unum needs for its files that I haven’t been able to submit (due to the numerous reasons I’ve outlined, both previously and additionally herein).
Unum is not saying that I don’t qualify for benefits, or that I’m not disabled — just that your file is missing some paperwork. And for this, Unum closes my file and discontinues the benefits rightly due to me under the policy. (I feel like a child who’s been smacked in the head for talking back to an adult.)
It’s just amazing to me how much money Unum spends on continually reviewing claims, but then an expert explained it to me on this website:
http://hcvadvocate.org/Hepatitis/hepC/LTD%20No%20Longer%20Disabled_2007.htm
“Although it will never be more than an educated guess, many believe that since insurance companies specialize in numbers and statistics, they use it to their advantage. They probably know that if they cancel 1,000 disability claims, a certain percentage, probably a large one, will not contest the termination. The money saved by those canceled claims more than covers anything they spend fighting the appeals of those who contest the decision.”
It is quite disingenuous of Unum to accuse me of not submitting this information in the time frame requested, when it granted one extension, and I requested another — the extension needed because Unum has refused to answer all of my questions regarding the information it is demanding. (Now I feel like a child who keeps asking “Why?” and Unum keeps saying “Because.”)
Additionally, Unum has not explained the purpose of this current review, or why it cannot complete another review of my claim with the information it already possesses (in the file its built up on me over the past decade). I believe Unum is required to provide “an explanation of why such material or information is necessary.” I don’t believe Unum has met that burden.
FORMS
The material and information Unum has cited as necessary consists of these two forms:
1. Disability Status Update (04/13)
2. Estimated Functional Abilities Form (01/12)
I will assume, just because I submit these documents in the future, that will not guarantee Unum will begin paying my rightful benefits again. In fact, when I do submit these documents, I expect Unum to review them with a fine-tooth comb for any word or phrase it can use against me. That’s a lot of pressure for me — to find a medical provider that will understand the stakes involved in completing these forms.
I would complete these forms myself and submit them if I thought Unum would accept the information that way. But, no, Unum requires me to find and pay a doctor to listen to my 25-year history (for however long that takes); write down what I say; review my records (for however long that could take); cash my check; complete the forms and return them to Unum; and then respond to any follow-up requests.
However, I question Unum’s need for the information requested in these forms, especially as it just paid a field representative to interview me personally, in my home, to collect updated information for its file.
FUNCTIONAL CAPACITY EVALUATION
One of the forms Unum is demanding is entitled “Estimated Functional Abilities Form.” As I have previously mentioned, I didn’t know what kind of doctor to see who has experience filling out this form, and who would be willing to do so for a disabled, intractable pain patient. A little more research into this medical specialty revealed the following:
“Two of the most common and important reports are a functional capacity evaluation report and a vocational expert report.
A functional capacity report comes from a standardized, objective test performed by a physical therapist. You will be tested on your ability to perform job-related tasks, such as lifting, pulling, pushing, standing, and sitting. The physical therapist uses this evidence to determine your ability to work. This report offers the best objective evidence of your true restrictions and is invaluable in a long term disability appeal.
After obtaining a functional capacity report, you may also need a vocational expert to evaluate your claim to challenge the insurance company’s report.”
http://www.hq-law.com/blog/LTDI/5-long-term-disability-appeal-mistakes.html
“You should also obtain independent medical, vocational, neuropsychological, and functional capacity evaluations to support your claim.”
My initial response to these kinds of tests is that they sound awfully painful and quite stressful to take. One of my issues with further examinations by doctors is the pain involved. A side effect of my chronic pain condition is that touch is painful and my prior experiences with doctors have mostly been, not only negative and stressful, but quite painful. For me to agree to suffer the additional pain of further examinations — especially at this time, as I have nothing stronger than aspirin to treat the resulting pain — I am going to need a very good reason for why it’s necessary. I don’t believe Unum has provided that reason.
Please explain why Unum requires this kind of evaluation, not only for my medical condition (as this is not a test to record pain levels — either before, during, or after activity), but seven years after its initial approval of my claim.
My research also uncovered the fact that functional capacity evaluations have not been proven to provide any credible information, and that 95% of patients who have these evaluations will then have it used against them to deny a disability claim.
It is impossible to gauge my functional capacity with a test taken on a certain date — pain levels vary, as does my ability to be physically active. Pain doesn’t arrive or recede on any schedule, and the level of day-to-day disability that goes along with the pain cannot be quantified by a 4-hour, painful test of strength.
All of these examinations required by Unum — after disability has already been proven — are expensive, excessive, physically painful, intentionally harassing in nature, and an unfair burden. And I don’t believe they rise to the level of Regular Care.
Requirements for continued benefits should not be more onerous than the original eligibility requirements. Once facts of disability — and intractable medical conditions — have been proven, they should not have to be continually proven, over and over again, as if they ceased to be true at some indeterminate point in time.
REGULAR CARE
[Contract definition at GLOSSARY-4 (8/1/2002) REV]
What does Regular Care include? If I am to use Unum’s definition, then it clearly does not include paying doctors to fill out forms.
Unum’s definition of Regular Care is redundant and confusing, but it appears to be based on the term “generally accepted medical standards.” I have previously stated that my home treatment regimen is considered Regular Care for a 25-year intractable pain condition, which does not require the supervision of a doctor. If Unum has decided that my treatment program is unacceptable, it would need to provide the reasons for that decision, supported by medical science and fact.
The standard of care for pain patients is different depending on how long the condition has existed and in what treatment stage the patient is in. For instance, what is standard and regular care for a pain patient on opioid treatment is not the same for a patient who is not. What is considered standard care after surgery — like physical therapy — is not the same for a patient who suffered through surgery decades ago.
And since I make my treatment decisions based on thorough research, I am confident my choices are supported by current medical science and opinion. My final response will include studies and opinions by medical experts that support my choice of treatment plan, including my recent choice of medical cannabis.
FOR THE RECORD, MY HOME TREATMENT PROGRAM
Within a 24-hour period, my home treatment program can (and usually does) include any of the following:
Stretching
Deep breathing exercises
Attempts at self-hypnosis
Aromatherapy
Control of light, sound, smells, social interaction, talking, smiling, stress
Memory/mental exercises
Writing therapy
Distraction therapies
Soft diet
Light massage
Music therapy
Awe therapy
Lots of aspirin
My home treatment program, as described in my handwritten comments submitted to Unum:
1. Disability Status Updated of 9/26/11, Section C, Information About Your Condition: Throughout a 24-hour period, a combination of various and numerous home therapies, at an average of every half hour. Memory/mental exercises. Try to do at least 1-2 household chores a day, if able. Writing therapy. For distraction from pain, watch some TV and can sometimes do some reading if headaches and nausea are bearable. Try to eat 1 meal/day. 0-4 hours of sleep.
Not meeting nutritional needs due to TMJ, nausea, and limited choices within required soft/liquid diet. Daily personal hygiene suffering. Increased insomnia and decreased REM sleep.
2. Disability Status Update signed 2/22/13, Section C, Information About Your Condition: No 24-hour period is the same except I usually eat, brush my teeth, and do the dishes every day. I watch the news to find out when and how my SS/Medicare benefits will be reduced or if the banks crashed the economy again. I pop aspirin and lie down when pain spirals out of control. I sleep if I am able, and I pretend to sleep when I am not. Deep breathing exercise and aromatherapy.
TYPE OF MEDICAL PROVIDER
What Unum doesn’t acknowledge in the Denial Letter is that I am trying to comply with Unum’s unending requests. My previous letters indicated my struggles (which Unum ignored); however, if Unum requires further details as to the doctor’s offices I contacted, please notify me.
Unum is demanding that I find and pay hundreds of dollars for a service that it has not adequately defined, especially for my specific medical condition.
But the contract says this:
“We may require you to be examined by a physician, other medical practitioner and/or vocational expert of our choice. Unum will pay for this examination.” [LTD-BEN-1 (8/1/2002) REV]
Since filling out Unum’s forms does not constitute Regular Care, then its demand for these forms is overly burdensome and not supported by contract language — but, at the very least, the request for these forms should include payment for the examination(s) by Unum.
Any health care provider can fill out Unum’s forms, but what level of provider will Unum accept? Only the most expensive kind? In New Mexico, mid-level medical providers have more responsibility than in most states, and some are able to prescribe medications. My understanding of Unum’s definition of “physician” would include my preferred options: nurse practitioners, physician assistants, and general practitioners. And so, I am requesting clarification (for the third time) on the type of medical provider Unum is requiring that I see.
Could Unum at least verify that it would accept these forms signed by the medical provider choices I have listed?
“The last medical records documenting regular treatment for your conditions were received in September 2011. We have not received restrictions and limitations from a medical provider treating you for your conditions since June 30, 2009.”
My Side:
1. It was around 2005 when my doctor opted out of Medicare, meaning I paid hundreds of dollars every month to see him, without any kind of reimbursement. This doctor charged extra to sign a one-page letter, and even more to fill out multi-page insurance forms — costs which are also not covered by insurance. (It’s expensive to be disabled.)
2. In 2010, my doctor of 8 years suddenly died — on the day before my monthly appointment.
3. I tried to find other doctors, and I reported to Unum in 2011 that I would be able to name an Attending Physician if I was accepted into a California program. I did not join that program. As I have stated in previous communications, the DEA is preventing legitimate pain patients from being treated with prescription medications. That treatment option is no longer available to millions of pain patients, including me.
4. It was in 2011 when I began to save money so I could try a different treatment program — not available in my state — and I wasn’t able to pay for one treatment while saving up for another.
“This information details the current extent of your disability, including restrictions and limitations. Despite our requests, you have not provided the Attending Physician Statement.”
I don’t agree that Unum has listed the only information it has that details the current extent of my disability. But when I receive the complete copy of my Unum file, I will be better able to determine the accuracy of this statement. And again, the “extent of my disability” hasn’t changed from the original filing of my long term disability claim (my condition was already advanced before the filing date), and past medical information is just as relevant today. The collecting of new (and even more) information is redundant, expensive, overly burdensome, harassing, and provides no benefit.
“The information you previously submitted established that you were eligible for benefits at that time. That information is insufficient to establish that you are presently eligible for benefits under your policy.”
I believe the information that “details the current extent” of my disability should not be restricted to forms signed by a doctor. And the current information contained in Unum’s file is what I can afford to submit — even more so now, since Unum discontinued my benefits.
ENCLOSURES
I submitted Dr. Reeve’s medical evaluation with my last letter, and I have enclosed with this letter the back-up documentation for that appointment, including a medical summary that I prepared (dated April 2013) and gave to his office (3 pages), and a copy of the patient information form dated 5/1/13 (2 pages). I’ve also enclosed a copy of the Enrollment/Re-enrollment Medical Certification Form signed by Dr. Nicholas J. Nardacci (who I believe is no longer in practice) dated 5/1/13 (1 page).
CONTRACT
Please be notified that the copy of the Contract recently sent to me by Unum is not an exact copy of the Contract I received from my attorney back in 2003. Now I will have to go through both copies, page-by-page and word-by-word, to figure out what the differences are.
REQUESTED DOCUMENTS
In order to prepare for filing my final response, please provide a copy of my claim/administrative file, including the following:
For the purposes of this section, the definition of “document” and “documentation” includes both electronic and written forms, and any versions thereof.
1. A copy of all documents, internal notes and memos, records, items and other information relevant to my claim for benefits, including all documents, records and other information that was: (a) relied upon in making the denial determination; and (b) submitted, considered, or generated in the course of my claim, without regard to whether such document, record, or other information was relied upon in making the denial determination. Please be sure to separate and note those items that were relied on in making the determination and those items that were not.
2. If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination, please provide copies of the specific rule, guideline, protocol, or other similar criterion.
3. The identification of each and every medical or vocational expert, including physicians or other consultants whose advice was obtained on behalf of the plan, his/her curriculum vitae, a copy of your request for his/her advice or opinion, and a copy of any notes, opinions or advice given by the expert, physician, or consultant.
4. All documentation and reports, including photos and surveillance videos, that were provided to Unum by its field representative who conducted the personal interview (or his employer) this year.
5. All documentation that Unum possesses — dated either before or after my initial enrollment date — regarding any credit reports, financial information, and/or employment information that includes my name or the names of any of my family members, along with the identify of the information source and the costs to Unum involved in procurement.
6. Unum’s protocol objectives and “primary plan directions” or ERDs (Expected Recovery Dates) calculated specifically for my claim file, along with the dates that would then correspond to Unum’s profitability reporting.
7. A list of any conflicts of interest that Unum may have, especially within the medical evaluations and testing industry.
8. All documentation that shows information collected by Unum for my claim/administrative file from MIB Group, Inc., GENEX Services, Inc., The Advocator Group and other Social Security advocacy vendors, and The Association of Life Insurance Companies (which operates the Health Claims Index and the Disability Income Record System).
9. All documentation and research performed on my file for the purpose of entering me in a Unum return-to-work program, including a list of any jobs which Unum feels I am qualified for and can perform, and any information on jobs available in my area.
10. All documentation which shows Unum’s position on medical cannabis.
11. Any analysis performed by Unum on suicide statistics in its claimant population, including the economic benefits and/or negative consequences to Unum’s financial condition.
I am requesting that Unum catalog and number each page (Bate-stamp) of the Requested Documents before sending to me. This will provide a guarantee by both parties that all Requested Documents were provided and received. It will also allow for easy reference during the appeal process and beyond. If Unum is unable to comply with this request, I will have to catalog the documents myself, including: by description and date, including number of pages for each item or document and total number of pages received. When completed, I will provide my list of received items to Unum; at that time, if anything is missing, Unum should notify me.
MENTAL ILLNESS CONDITIONS
“We previously communicated the policy limitation for mental illness conditions applicable to your claim on April 14, 2014.”
I don’t understand why you are mentioning this policy limitation, as it does not apply to me. If Unum is attempting to say that my disability is due to a mental illness, I will need further clarification before I attempt to fully respond. Even though Unum has objective evidence of TMJ and degenerative disk disease — some of the underlying causes of my disabling, intractable pain condition — is Unum now contending that my pain is caused by mental illness?
Mental and behavioral conditions are part of most disabilities, and are referred to as “comorbid.” This means the mental condition is secondary to the physical condition. And in my case, the physical condition is independently disabling.
“We received and reviewed a copy of your Social Security Disability file.”
Yes, I know, multiple times.
“They approved benefits based on Major Depressive Disorder and Anxiety Related Disorders on July 26, 2004.”
Again, I don’t understand why Unum is bringing up this issue, especially after seven years of paying benefits. But since I have never seen a document from Social Security that indicates this reason for approval, please forward a copy (under separate cover) of the document Unum is relying on to make this statement.
Is it Unum’s opinion that the approval of benefits by Social Security were based solely on this comorbid condition? Because it is my understanding that the qualifications for Social Security Disability are more stringent than Unum’s, and include much more than the specific medical conditions of an applicant.
“You may continue to experience mental health impairment. However, we have previously paid the maximum 24 months of benefits for disability due to mental illness under your Long Term Disability policy.”
Unum has “paid the maximum 24 months of benefits for disability due to mental illness” for every single insured that has been approved for disability and has received benefits past the 2-year mark. Yes, I understand that includes me. I also understand that Unum has denied insureds under this mental-health maximum with medical conditions like AIDS and heart attacks. And now TMJ and intractable pain?
A lot of Unum’s actions are discriminatory, but this mental health loophole really highlights Unum’s ability to discriminate.
COMMUNICATION
All communication between Unum and myself needs to be in written form, including a confirmation of receipt for each letter between us. Unless Unum notifies me otherwise, I will assume that it is receiving my letters via fax.
Since I don’t have a home fax machine, sending correspondence to Unum in this manner is unduly burdensome. Therefore, I am requesting that communication during the appeal process be via email. I know that Unum benefits in many ways from a long, drawn-out appeal process, but I will benefit from speeding up the process to reflect the technology of 2014. Please provide me with your email address at your earliest opportunity.
CHECK
Unum’s correspondence dated 9/12/14 from Angela Fox forwarded a “final benefit check,” with the following language:
“With the issuance of this check, payment for your claim is now complete. Please inform us if you receive other income, such as Social Security. Benefits and/or deductions for a partial month are payable and/or deducted at a daily rate that is 1/30th of the monthly rate.”
Please be notified that, by cashing this check, I am not agreeing with Unum that my “claim is now complete.” The evidence of that is in this intent to appeal. Also be notified that I will write-in my own language indicating this fact, above my signature, when I deposit this check with my credit union.
The second sentence indicates that Unum wants to be informed if I receive other income, such as Social Security. Since Unum is well aware that I receive Social Security Disability benefits, I am confused as to what further information is “requested.”
ACTIONS BY UNUM
Considering Unum’s dual role as insurer and plan administrator, I believe the actions by Unum on my claim are arbitrary and capricious and an abuse of discretion.
Therefore, I am requesting that Unum pay interest on the total amount of my withheld benefits, from the date of denial up to when they are re-instated. For the record, I am also requesting that Unum pay a penalty for terminating my benefits for its own profit-motives, when the appropriate course of action would have just been to answer my questions and give me some time to comply to its demands.
And since the Attorney General’s office refuses to act, I am also requesting that Unum hire and pay an independent agency to undertake a market evaluation to determine if it is in violation of state laws or engages in unfair claims practices.
IN CLOSING
I have decided on a medical cannabis treatment program — because I showed symptomatic progress gradually throughout the year I was able to be in it. Just because I could not afford to renew doesn’t mean I didn’t experience any progress.
I could not afford the renewal to the medical cannabis program in New Mexico; I’m trying to save money to move to a state where I can afford my chosen treatment; and Unum wants me to spend money on seeing a doctor to fill out forms. Not only that, but Unum believes it is good business practice to demand that I spend more money, and at the same time, discontinue my benefits.
Mr Beaudette, I understand you’re just doing your job, and that it’s not an easy one — but why does doing your job have to cause me physical pain and cost me so much money?
I may be tired of fighting, but I’m not dead yet,
Johnna Stahl
cc:
VIA EMAIL
john.gaherty@state.nm.us
Mr. John Gaherty
Compliance Director/Investigations Bureau
Office of Superintendent of Insurance
P.O. Box 1689
Santa Fe, New Mexico 87504-1689
VIA REGULAR MAIL
Mr. Thomas E. Perez, Secretary, Department of Labor
U.S. Department of Labor
200 Constitution Ave. NW
Washington, DC 20210
Letter to Unum 8/25/2014
August 25, 2014
VIA FAX 800-447-2498
Mr. Donald Beaudette
Unum
The Benefits Center
Post Office Box 100158
Columbia, SC 29202-3158
RE: Unum correspondence dated July 24, 2014
Unum Life Insurance Company of America
Claim No. ***
Policy No. ***
Under threat of the discontinuance of benefits, I have been diligently searching for a doctor to complete Unum’s forms. In addition to previous efforts, this past week I have visited numerous doctor’s offices in my area, asking if they take Medicare and if the doctor is willing to fill out disability insurance forms (which I brought with me). Here are some of the responses I have received so far:
1. We are not taking new Medicare patients at this time.
2. You can bring the forms to the appointment, but there is no guarantee that the doctor will fill them out.
3. We are booked up with children getting check-ups for school, and the first available appointment for a new patient would be sometime in September.
4. There are only nurse practitioners at this clinic, and I think you need a doctor to sign disability insurance forms. Ask your insurance company.
Since Unum neglected to answer all of the questions in my previous letter, I am now forced to ask them again. What treatments, specialties, or doctors does Unum believe are included in “generally accepted medical standards” for the treatment of intractable pain? What kind of doctor will Unum accept to fill out these forms? Can I use a chiropractor? An acupuncturist? Since a nurse practitioner is less expensive (and just as qualified to ask questions and fill out forms) than a specialist, that would be my choice. If Unum will not accept the services of a Nurse Practitioner, I need to know why it believes these medical professionals are not qualified for the job.
The problem is, of course, that if I don’t choose the doctor or medical specialty that Unum considers to be “appropriate” for my “disabling condition(s),” then I continue to be at risk for the discontinuation of my benefits — in fact, my choice could give Unum the ammunition it needs to do just that. And I would have paid for a service that I don’t need, and one that Unum won’t accept.
Additionally, is Unum requiring that I choose an available doctor that doesn’t take Medicare?
When Unum can answer my questions, I will be able to narrow my search to the type of providers that Unum demands.
The other problem, as mentioned in my previous letter, is how difficult it will be to find this medical practitioner, and the fact that Unum’s deadlines do not give me enough time to find a doctor, make and keep an appointment, then wait for the doctor to produce the completed forms. As a patient, I cannot ensure that a doctor completes insurance forms by a certain date.
Therefore, I am requesting an extension of the August 30th deadline. I cannot force a doctor to take me on as a new patient to fill out Unum’s forms, and I will need more time to find one who will.
In the interim, I am enclosing a copy of a medical evaluation dated 5/1/13 generated by Dr. Anthony Reeve for inclusion in my file.
Now, to address additional issues brought up in our latest correspondence:
First, let’s look at Unum’s definition of “Regular Care”:
Regular Care means:
– you personally visit a physician as frequently as is medically required, according to generally accepted medical standards, to effectively manage and treat your disabling condition(s); and
– you are receiving the most appropriate treatment and care, which conforms with generally accepted medical standards, for your disabling condition(s) by a physician whose specialty or experience is the most appropriate for your disabling condition(s), according to generally accepted medical standards.”
For more hints on what Unum is talking about, I googled “generally accepted medical standards” for the treatment of “intractable pain,” and only received 8 hits, none of which were helpful.
It is my position that “the most appropriate treatment and care” for my disabling condition is a home treatment program, generally accepted by medical standards for the treatment of long-term intractable pain.
It is also my position that a home treatment program for intractable pain does not medically require a personal visit to a physician, especially for the specific reason of filling out insurance forms.
“Preliminarily, we would like to address your dissatisfaction with our periodic requests for updated information. We take exception to your remarks characterizing the handling of your claim and believe that you may have misunderstood the nature of our requests. Please note that we have not received medical records since September, 2011, and our current request cannot reasonably seen as excessive.”
You may have not received “medical records,” which are expensive to obtain, yet I have filled out all of your “periodic” forms, in detail, keeping you updated as demanded. And when it costs so much money to obtain the reports Unum is requesting, then yes, it is excessive. After all, I have already paid for every single medical report for the last 25 years, all of which are contained in my file.
And what about the personal interview I was forced to have with your field representative? Is that not considered an update? (One that I didn’t have to pay for, by the way.) And why am I not allowed to read the report?
“Insured’s have a continuing obligation to provide proof of loss at regular intervals as necessary to permit the evaluation of their claim.”
Proof of what loss? The loss of the ability to be employed? As I stated previously, you have been given ALL of that information. Unum has evaluated my claim, then re-evaluated it, then approved it, many years ago; and yet, Unum is continually re-evaluating it. I’m just not getting that Unum understands the definition of “intractable.”
To me, “proof of loss” means “proof of disability.” Please explain what you mean by “proof of loss,” and why Unum thinks that I am obligated to continually supply proof that I am disabled, especially considering the definition of intractable pain. This definition was created by the medical industry, and is considered “generally accepted by medical standards.”
“It appears that you are suggesting that your condition is permanent and that because you feel you will not benefit from further medical treatment, you should not be required to see a physician from time to time. We are unable to accept your characterization of your condition as permanent and untreatable, and must continue to ask you to obtain information from a treating physician to allow us to understand your current conditions and any restrictions and limitations.”
I am not just suggesting that my condition is permanent and untreatable, the very definition of my disability says just that. As for benefiting from further medical treatment — the answer to that is also found in the definition of my condition, as I’ve already tried all the “standard” treatments offered by the medical industry. And as I’ve mentioned, these “standard” treatments almost killed me (besides being incredibly expensive).
So, if you are requiring me to “see a physician from time to time,” then I need more specifics as to what kind of physician Unum will accept in my case. Because I am unaware of any medical specialty that involves overseeing a home treatment plan and filling out insurance forms.
As to Unum’s contention that my condition is treatable — what is that opinion based on? Perhaps Unum doesn’t agree with the medically-accepted definition of intractable pain? Does Unum think it knows better than doctors how to treat and manage my disabilities? Does Unum want to be my doctor?
The restrictions and limitations are that I am disabled and physically unable to work. Again, I am not getting that Unum understands the definition of “intractable.” Oh, I know why Unum wants these restrictions and limitations constantly updated and written down by doctors — to find loopholes in the language a doctor uses to complete the forms, so as to determine me fit for some kind of employment and discontinue my claim.
“Medical conditions and individual circumstances may change over time…”
Intractable and degenerative conditions do not change, except to get worse. And by “individual circumstances,” I’m guessing you mean economically. So, didn’t your field representative confirm that I haven’t won the lottery?
“Please understand that so long as your claim remains open, we will require updated information…”
“…and accordingly, we must continue to ask for updated information for the duration of your claim.”
I assume Unum is saying that my claim will remain open until I die, so why don’t you just state that? “Unum’s harassment will continue until your benefits are unfairly denied or upon the date of your death, whichever occurs first.”
“At this time, while your claim is open and being paid, we are not prepared to release copies of additional file documents.”
Oh, I know that Unum is not legally required to turn over a complete copy of my file unless it chooses to deny my claim — which, I might argue, it already did, back in 2003. My question is, why can’t I have a copy of this one report?
“We enclose a complete copy of your policy.”
When I asked for the signature page, I was looking for the one that included MY signature.
“If we do not receive the requested information by August 30, 2014, your claim will close and no further benefits will be paid.”
I am trying to obtain the information demanded by Unum, and if Unum stops my benefits on 8/30/14 because of its unreasonable deadlines, then I’m going to spend that money on a lawyer, not a doctor.
I await Unum’s response.
Johnna Stahl
Letter to Unum 7/7/2014
July 7, 2014
VIA CERTIFIED MAIL
RETURN RECEIPT REQUESTED
Mr. Donald Beaudette
Unum
The Benefits Center
Post Office Box 100158
Columbia, SC 29202-3158
RE: Unum correspondence dated June 16, 2014
Unum Life Insurance Company of America
Claim No. ***
Policy No. ***
Dear Mr. Beaudete:
Every time I receive mail from Unum, the responses are “requested” under the threat of a loss of benefits. This causes a lot of anguish — from anger, to anxiety, to fear — and automatically makes our relationship adversarial. I’m sure Unum is aware of the fear its communications provoke in the disabled population, as its processes appear actually designed to do so.
Unum’s latest correspondence comes with the following, familiar threat:
“Unum will deny your claim, or stop sending you payments, if the appropriate information is not submitted.”
I guess Unum is the sole decider of what is “appropriate information”?
So, face losing my benefits (and an eviction), or comply with Unum’s demands?
I am so very tired of being bullied. And yet, as a disabled person, I feel extremely vulnerable picking a fight with Goliath (I mean, Unum). A little bit of recent research on Unum and its practices has caused enough fear in me to copy this letter to the people who are supposed to be making sure Unum abides by the 2004 multi-state settlement agreement — the people who are supposed to be protecting people like me.
What follows are my responses to Unum’s latest correspondence, received via regular mail on June 21, 2014.
I will begin with my definitions:
1. Definition of Unum
Unum is a mega-corporation that’s sole purpose is to create profit for its shareholders. The purpose of any and all activity by Unum employees and contractors is to search for reasons to deny claims and sever benefits to meet the goal of creating profit for the corporation.
Experts see Unum’s processes as favoring the insurer, and representing a conflict of interest, since the insurance company acts as both payor and reviewer of the policies it sells.
I believe this blog post explains your processes both thoroughly and succinctly:
2. Total and Permanent Disability Are the Same Thing
http://www.ssa.gov/dibplan/dqualify4.htm
“The definition of disability under Social Security is different than other programs. Social Security pays only for total disability. No benefits are payable for partial disability or for short-term disability.
‘Disability’ under Social Security is based on your inability to work. We consider you disabled under Social Security rules if:
You cannot do work that you did before;
We decide that you cannot adjust to other work because of your medical condition(s); and
Your disability has lasted or is expected to last for at least one year or to result in death.”
https://en.wikipedia.org/wiki/Total_permanent_disability_insurance
Ballentine’s Law Dictionary defines a permanent disability as one that “will remain with a person throughout” his or her lifetime, or he or she will not recover, or “that in all possibility, will continue indefinitely.”
3. Definition of My Disability, Intractable Pain
A pain state in which the cause of pain cannot be removed or otherwise treated and which in the generally accepted course of medical practice no relief or cure of the cause of the pain is possible or none has been found after reasonable efforts that have been documented in the physician’s medical records.
4. Definition of Intractable
Oxford Dictionaries: Hard to control or deal with: intractable economic problems, intractable pain.
MedicineNet.com: Intractable: Unstoppable. For example, intractable diarrhea is diarrhea that can’t be stopped, even with medication, and intractable pain is pain that can’t be stopped, even with medication.
The Free Dictionary: Difficult to alleviate, remedy, or cure: intractable pain.
Synonyms: Unmanageable, uncontrollable.
5. Definition of Degenerative (as in Degenerative Disk Disease, one of the causes of my constant pain)
Google: adj. (of a disease or symptom) characterized by progressive, often irreversible deterioration, and loss of function in the organs or tissues.
Merriam-Webster: medical : causing the body or part of the body to become weaker or less able to function as time passes.
6. Definition of Health (Regular) Care
In America, health care is a privilege, not a right — it is a luxury, not a necessity. But it should not be a requirement, as Unum contends, especially for the permanently disabled. For instance:
a. Wearing glasses is painful, and I might alleviate this daily pain by undergoing laser surgery — if I were willing to have eye surgery and also willing to pay for it — neither of which are true. The amount of pain that might be relieved is not worth the money for the procedure’s cost or risks; and
b. Recently, I suffered nerve damage in my left index finger during a test for eczema. (The test of which proved to be painful, expensive, and useless to me.) When the pain is sharp, it sends referred pain throughout my hand. I could seek treatment for this nerve pain, perhaps with a steroid injection — but the cost of the treatment, its potential for short-term relief, and the long-term risks, are not worth it.
7. “What information is needed as proof of your claim?” (Page 2 of Unum’s letter)
It is my contention that all information has been provided to Unum for proof of my disability claim, as evidenced by Unum’s eventual approval of same in 2007.
This proof includes information provided by numerous doctors, Guardian Life Insurance Company of America, and the Social Security Administration.
And I continue to provide updated information, as Unum has continually demanded, including a recent lengthy personal interview with your field representative.
I understand why Unum continues to request information, but I’m beginning to believe that no amount of information will be sufficient. Ever.
8. Unum’s Re-evaluations/Re-certifications
Considering the above definitions of my disability, please provide Unum’s legal basis for requiring continual re-certifications of same, specifically for the disease of Intractable Pain.
9. “You must be under the regular care of a physician in order to be considered disabled.” (Page 2 of Unum’s letter)
Please provide Unum’s legal basis for this claim.
From the Consumer Bill of Rights and Responsibilities that was adopted by the US Advisory Commission on Consumer Protection and Quality in the Health Care Industry in 1998:
“You have the right to ask about the pros and cons of any treatment, including no treatment at all. As long as you are able to make sound decisions, you have the right to refuse any test or treatment, even if it means you might have a bad health outcome as a result.”
10. “We may request that you send proof of continuing disability indicating that you are under the regular care of a physician. This proof, provided at your expense, must be received within 45 days of a request by us.” (Page 2 of Unum’s letter)
Let’s start with this fact: I am not sick, I am disabled. If I’m sick, I might need to see a doctor; since I’m disabled, I might need to see a doctor if I get sick. In other words, just because I am disabled, that does not mean I am sick and need to spend money on doctors, treatments, or tests. Been there, done that.
I spent 25 years (and all of my money) seeking help from the medical industry — and pain specialists and their “treatments” almost killed me. Now, Unum is requiring that I seek treatment again from the medical industry — services I neither want or need. In fact, it is only Unum’s needs that we are talking about here. And I don’t understand why I have to pay for a corporation’s need to make a profit.
I will need Unum’s definition of “regular care,” specifically for the disease of Intractable Pain (please refer to my definition of IP). What kind of doctor or specialist is Unum requiring that I see and “provide at my expense” (for the purpose of filling out one of its many forms, this one for updating disability status)?
I have contacted numerous doctors in Albuquerque, asking office staff if the doctor will complete this form, and how much it would cost. Since I am not seeking any ongoing treatment from these doctors, it appears it is very easy for them to turn down my business.
One doctor’s office informed me that it only handle worker’s comp claims, and advised me to hire an attorney. One doctor’s office said it no longer worked with patients who had disability coverage through Unum. One doctor’s office never responded.
It appears to me that Unum is requiring that I pay for an Independent Medical Examination, which is a very expensive undertaking, and one that seems totally unnecessary in my case. Since I am covered by Medicare, is Unum asking Medicare to cover the expenses of an IME, specifically for Unum’s needs? If so, I will need to communicate directly with CMS and determine beforehand if this expense is covered or not.
Please provide Unum’s legal basis for requiring that these continual and unnecessary requests for updated “proof” of disability be provided, and at my expense. Because as I see it, the only basis for continuing to harass me — and demand that I pay for services I neither want or need — is for fishing expeditions so that Unum can search for ways to sever my benefits.
11. “Restrictions and limitations preventing you from working” (Page 1 of Unum’s letter)
These have been provided over and over again, and only increase as time passes. This continual request for information, in my opinion, can only be defined as harassment of the disabled.
12. Doctors and Pain Patients
Please provide Unum’s definition of “generally accepted medical standards, to effectively manage and treat” the disease of Intractable Pain.
And if Unum can find a pain specialist who disagrees with my home treatment plan, previously and thoroughly detailed in Unum’s file, please let me know.
Because I am an expert on the management and treatment of Intractable Pain, I know that “generally accepted medical standards” for the treatment of pain only include those expensively accessed through the medical industry — and all of these “standard” treatments (including both the under-treatment and over-treatment of pain) are actually killing people, in case this is news to Unum:
A total of 43,000 deaths were reportedly caused by opioid dependence in 2010. Based on the information of each death, it’s likely that opioid users are more likely to die 46 years earlier than non-users. https://news.vice.com/article/un-drug-report-america-still-loves-weed-while-the-world-is-hooked-on-pills
I understand that Unum will profit off of my death, and would be happy to see me again seeking treatment back in the medical industry. But, as a pain patient, I have the right to refuse ANY treatment, both under state and federal laws. Besides which, any pain specialist worth his salt would advise a long-term IP patient to create an at-home treatment program — especially considering not too many pain patients can afford to keep paying for short-term and ineffective treatments.
In fact, your field representative mentioned that Unum has a problem with its belief that my condition is not improving — is this really any of Unum’s business? Is Unum going to next tell me how many more treatments I must try, and continue to try, to be considered disabled?
So, please, be very plain in your definition: Is Unum requiring that I go back to seeking expensive, harmful, and useless treatments through the medical industry? Is that the only way the corporation “proves” that the disabled continue to be disabled?
I would really like to know in advance, for budget purposes, how much money Unum expects me to throw away every year within the medical industry.
And since ignoring medical recommendations from primary care physicians is a common theme with Unum, I sure hope its one and only suggestion for the type of doctor I am being required to see is not a primary care physician.
“Two-thirds of U.S. physicians are now specialists, well above the level in other rich democracies, where roughly half fall into that category.” http://newsinteractive.post-gazette.com/longform/stories/poorhealth/
Finding access to a doctor that still takes Medicare, will work with Unum, and would be willing to take on an Intractable Pain patient may prove to be difficult.
And I’m just wondering how Unum handles patients who’s treatment plans consist solely of prayer. Is there a religious exemption that can save me from Unum’s continual harassment? Perhaps under the now-infamous Religious Freedom Restoration Act?
13. Requests for Documentation
Although I have previously received a copy of the policy, it did not come with the signature page. Please forward a copy of same.
Unum’s field representative indicated that I have the right to a copy of his report from the site interview. Please provide same.
14. HIPAA and the ACA
Unum’s Authorization Form CL-1021-AUTH (04/13) states:
“The privacy protections established by HIPAA may not apply to information disclosed under this authorization, but other privacy laws do apply.”
It goes on to state:
“If I do not sign this authorization or if I alter or revoke it, Unum may not be able to evaluate my claim(s), which may lead to my claim(s) being denied.”
All of Unum’s forms contain the threatening language of denying or discontinuing benefits if the claimant does not follow Unum’s “requests” and instructions, without deviation. And I’m beginning to believe that Unum requests and requires more information than federal and state laws (along with its contract language) allows, using these threats to force compliance.
For instance, I believe the Affordable Care Act requires insurance companies to fully comply with HIPAA, but as your form language indicates, Unum Group does not. At this time, I am requesting that you send me a revised authorization form that does not necessitate me signing away my HIPAA rights.
15. Additional Requests
I am requesting an extension of Unum’s requirement to “establish care” by July 30, 2014, until the above issues have been discussed and resolved.
I am also requesting that you notify my previous employer, Beirne, Maynard & Parsons, of the firm’s possible liability as a co-fiduciary under ERISA for Unum’s actions and the issues delineated herein.
Signed,
Johnna Stahl
cc:
VIA REGULAR MAIL and EMAIL
garyking2014@gmail.com
info@garyking.org
Mr. Gary K. King
Office of New Mexico Attorney General
P.O. Drawer 1508
Santa Fe, NM 87504-1508
VIA EMAIL
Insurance.PFR@maine.gov
Department of Professional & Financial Regulation
Bureau of Insurance
#34 State House Station
Augusta, ME 04333-0034
VIA EMAIL
cis.complaints@tn.gov
TN Department of Commerce and Insurance
Insurance Division
500 James Robertson Parkway
Nashville, TN 37243
VIA EMAIL
doicss.mailbox@state.ma.us
Commonwealth of Massachusetts
Division of Insurance
1000 Washington St, Suite 810
Boston, MA 02118-6200
VIA EMAIL
john.gaherty@state.nm.us
Mr. John Gaherty
Compliance Director/Investigations Bureau
Office of Superintendent of Insurance
P.O. Box 1689
Santa Fe, New Mexico 87504-1689
VIA EMAIL
patricia.torres@state.nm.us
Ms. Patricia Torres
Consumer Assistance Bureau
Office of Superintendent of Insurance
P.O. Box 1689
Santa Fe, NM 87504-1689
VIA REGULAR MAIL
Mr. Thomas E. Perez, Secretary, Department of Labor
U.S. Department of Labor
200 Constitution Ave., NW
Washington, DC 20210
11/11/2014, Doctors Charging Medicare Millions To Test Seniors for PCP, Says Consumer Watchdog
http://www.cnbc.com/id/102175134#.
“The WSJ analyzed 2012 Medicare billing data and found that dozens of pain management doctors were making more money from Medicare payments for drug testing than from treating patients.”
11/17/2014, Wikipedia May Predict The Next Global Health Crisis
http://www.huffingtonpost.com/2014/11/17/wikipedia-search-epidemics-disease_n_6161202.html
“Scientists may one day be able to predict epidemics simply by analyzing what people are searching on the Internet. Researchers at the Los Alamos National Laboratory in New Mexico found that a surge in Wikipedia traffic for certain disease-related articles predicted the large-scale spread of illnesses in several world locations, sometimes as long as 28 days before official spikes were recorded. The findings were published online Thursday in PLOS Computational Biology.”
Hey, Wikipedia, what does your traffic say about the opioid “epidemic”?
All Things Chronic 