October 24, 2014
VIA FAX 800-447-2498
Mr. Donald Beaudette
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
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).
“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:
“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.
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.”
“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.
[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:
Deep breathing exercises
Attempts at self-hypnosis
Control of light, sound, smells, social interaction, talking, smiling, stress
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.”
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.
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).
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.
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.
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.
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.
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,
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
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