Insurance Investigators: An Inside Look At Their Techniques

We’ve often mentioned insurance company investigators and their tactics as extremely adept at developing reasons to deny legitimate disability claims. Insurance companies like to hire former FBI agents and police detectives who have been specifically taught to treat their targets as adversaries and be cynical of any answers – which they innocently refer to as being professional. These investigators have undergone specialized training on how to dig up information and how to conduct interviews that can be twisted against claimants and used by claims examiners to deny disability claims. Due to our connections, our firm has seen some of the confidential training materials used by disability claims operations that help provide insight into the investigative techniques and methods used to interview claimants. This information can be invaluable to claimants, allowing them to more properly prepare for the interview, whether it’s a scheduled appointment or an unannounced visit. Today’s blog is going to breakdown and summarize some of the key points to help you handle an interview and understand the underlying purposes for the questions.   Continue reading

Cigna’s Market Settlement Causes Re-Evaluation of Many Denied Disability Claims

Cigna has agreed to a wide-ranging re-evaluation of its disability claim denials from 2008, 2009, and 2010 in California and from 2009 and 2010 in Connecticut, Maine, Massachusetts, and Pennsylvania.

The settlement affects certain long term disability claims in all of Cigna’s units – Life Insurance Company of North America, Connecticut General Life Insurance Company, and Cigna Health and Life Insurance Company.

After multiple complaints to the insurance commissioners in these states, regulators found that Cigna ignored Social Security decisions, discounted the findings of independent physicians, and didn’t consider workers’ compensation records when evaluating claims.  These practices forced Cigna to set aside $77 million for payments to current and past claimants who were improperly denied their disability benefits as well as to pay fines to the states.  In addition, the settlement requires Cigna to:

  • Establish a remediation program in which the companies’ enhanced claim procedures will be applied to certain previously denied or adversely terminated claims for residents of California, Connecticut, Maine, Massachusetts, or Pennsylvania.
  • Enhance claim procedures to improve the claims handling process to benefit current and future policyholders.
  • Participate in a 24 month monitoring program conducted by the insurance departments of each state, involving random sampling and on-going consultations.
  • Undergo a re-examination upon completion of the monitoring period.
  • Pay fines and administrative fees totaling $1.7 million.

“This regulatory action is intended to provide long-awaited relief for consumers who have a right to expect that their carrier will make good on contractual promises.  As regulators, we hold carriers accountable for adhering to laws and regulations of each state in which they conduct business.  This settlement resulted from market conduct exams and encompassed issues of serious concern.  It is a solid example of regulatory cooperation in protecting the policyholders of Connecticut and other jurisdictions.” said Connecticut Insurance Commissioner Thomas Leonardi.

For the official press release from the California Department of Insurance, click here.

For a copy of the Maine market conduct examination, click here.

The full regulatory settlement can be found here.

Although not quite the magnitude of UNUM’s market conduct settlement a few years ago, Cigna’s agreement can have a great impact on those claimants who were improperly denied their disability benefits.

If you think you may be eligible to have Cigna’s denial of your long term disability claim reviewed or have any questions about this settlement, please feel free to contact our offices toll-free at (855) 828-4100 or visit our website to sign up for a free consultation.

 

Does the Affordable Care Act Affect Your Disability Insurance?

With last week’s Supreme Court ruling confirming the constitutionality of the Patient Protection and Affordable Care Act (PPACA), informally referred to as Obamacare, it’s now time to start looking forward to the parts of PPACA that have not yet taken effect and analyze the repercussions.  While it may not directly affect the disability insurance market, the PPACA will affect every individual currently receiving benefits.  Health insurance is an important part of physical and financial well-being, and the PPACA dramatically changes how we view health insurance in this country.  In the opinion of our firm, the PPACA helps most individuals, especially those people who are experiencing substantial medical problems in their lives.  Today I am going to break down the PPACA into its 10 Titles and touch on how each title may affect disabled individuals and specifically how they relate to disability insurance claims.  Continue reading

Employee Turnover and Ethics in the Disability Insurance Industry

We’ve recently had several clients who have had utterly terrible experiences with their claims examiners.  From rudeness to laziness to incompetence, it seems like some insurance companies are not only trying to save money by denying claims but also by hiring less qualified staff.  Companies and claims departments (who know better!) are hiring, training, and even promoting claims examiners who don’t return phone calls, provide wrong information, or become defensive or non-responsive when asked claim questions that deserve an answer.  After complaining, some insureds are reassigned to another claims examiner who in turn answers their questions.  Although this may be seen as a win, all that’s been accomplished is a game of musical chairs.   Continue reading

Insurance Company Manipulation of Herniated and Degenerative Disc Claims

Many people have some form of degenerative back condition, ranging in severity.  Certain activities and professions can aggravate these symptoms into a condition that makes working almost impossible.  Several types of doctors, such as interventional cardiologists and radiologists, are susceptible to back injuries and herniated discs from wearing heavy lead aprons.  While there are several types of surgeries that may help relieve symptoms, including discectomies, insertion of rods and pins, and spinal fusions, these surgeries do not always work.  Before and even after such surgeries, patients can suffer from numbness, weakness, and loss of sensation in their extremities.  When the conditions become unbearable, many people decide to stop working and file for their disability insurance benefits.  However, getting your disability claim paid is not as simple and easy as it was promised.  Here are a few ways insurance companies defend against these claims to delay or not pay benefits. Continue reading

Really, it’s a “win-win” ?!?

The term win-win has become a cliché but still applies in some scenarios.  Some of our best and most satisfied customers are agents and brokers.  Working with us is a win for both the agent and the insured — and frankly, the insurance company as well.

One of the main goals of an agent is to keep their current clients happy in order to generate goodwill and referrals.  A great way to achieve that goal is by helping their clients, at their greatest time of need when a disability has struck and the claim process is unfolding, see that their claim is paid in the best and easiest manner possible.  That is where and when a referral to our firm can make a positive difference.

When a disability claim is filed, the promises made when the policy was bought and the reputation of the agent are put on the line.  The client sees the agent as an extension of the company, but claim departments view the agent as just a parrot for the insured.  Neither is true – but the agent is still stuck in the middle.  An agent’s reputation is priceless.  Royal Claims Advocates allows the agent to get out of being trapped in this no-win situation between his client and the insurance company and enhances the agent’s reputation as a skilled professional.

Our firm is focused solely on helping insureds throughout the country get their disability claims filed properly and making sure their policy benefits are paid in full and on time.  We don’t compete with agents or sell insurance products.  We work behind the scenes with our clients, simplifying what can become a very cumbersome and lengthy claim process and making it easier for insureds to obtain their rightful benefits without undue stress and strain.  The insurance company gets the information needed to process and approve the claim without extensive reviews, invasive demands, and protracted delays.

The ease in which clients are able to go through the claims process and collect on the promises when the insurance was sold reflect on the agents.  Clients come to see their agents as trusted resources, professionals who are able to ensure that promises made are promises kept.  All this takes is for the agent to make a simple connection between the client and our firm, when our services can be of assistance.

When a client contacts them about filing a disability claim or has difficulty dealing with the claim process, agents refer those clients to us.  Our team of experts – medical, occupational, investigative, and financial – immediately start working to understand and address their concerns.  Recognizing the trust placed in each party, agents are kept in the loop throughout the claims process.  Clients’ service expectations are not only met but exceeded by our consulting services.  The time, energy, and resources of agents stay focused on their core business, which is not the adjudication of disability claims.

A disability claim that is clear, concise, and complete produces a “win-win-win” situation, for the insurance company, the insured, and the agent.  The insurance company saves time and expenses on the claim adjudication process, which reflects positively back on the agent as well.  There is no downside for an agent or broker to refer a client to us.  We make sure your clients receive their promised benefits, improving your professional reputation, at no cost to you!

If you are an agent or broker and would like more information on our firm, please visit our website or give us a call at (678) 828-4100.

The Profits Behind Denying Disability Claims

Happy New Year! I hope your holidays were enjoyable, and we wish you and yours a very happy and prosperous 2012.

Many people realize too late the voracity of which insurance companies attack insureds’ credibility and practice a policy of deny first, ask questions later.  What many people do not understand are the reasons why.  Practical business sense says that putting your customers first and practicing strong customer service will keep customer loyalty.  Insurance companies follow these rules when selling and updating their insureds’ policies.  But these rules are at best only given lip service in the claim departments after a claim is filed.  Our first post of the year is going to discuss the reasons behind the change in rules once you’ve filed your disability claim.

Since the late 1970’s, insurance companies actively marketed “own-occ” policies to white-collar professionals.  These people were specifically targeted because they were less likely to stop working due to the time they had invested in their education, high salaries, and enjoyment of their careers.  These policies, in addition to paying if a claimant could not work their specific occupation, were also non-cancellable, and the premiums were fixed.  These policies became very popular!  The market became more competitive with more insurance companies offering more attractive measures, such as reducing underwriting standards and lower prices.  Other features – coverage without a detailed medical history, no mental health exclusions, lifetime benefits, and 6% cost of living increases – were also added to policies, resulting in a “boom” of sales.

The economic expansion and investment returns during the ’80’s and ’90s enabled insurance companies to invest the premiums from these liberal policies and earn substantial returns.  These returns were predicted to continue but stopped after the late ’90s.  At the same time, the income for many professional careers grew stagnant and even declined in some specialties, which caused many professionals to reconsider whether they should continue working through their disabilities and instead file for benefits on their disability policies.  This sudden influx of claims coupled with the declining rates of return on the invested premiums turned the “own-occ” policies into a very unprofitable field, costing insurance companies millions of dollars.

This lack of profitability caused insurance companies to start focusing on the “management” of these claims in order to make the policies profitable again.  Insurance companies started reviewing claims and looking for every and any reason or interpretation of policy language they could use to deny otherwise legitimate claims.  Policy forms were revised, and new reasons were constructed to deny benefits.  Claim payments were slowed down or even stopped while investigations were ramped up.  The methods that came about during this period are well known today to insureds who have gone through the experience of filing a disability claim: lost documents, unannounced visits, field interviews, “independent” medical exams, financial audits, surveillance, and many other dubious tactics.

Insurance companies have realized the profitability of fighting claims, which has developed into its own billion dollar industry.  We know – that’s where we were taught all about disability claims and how to “defend” against them.  This is why insureds must stay vigilant and why advocates are often necessary to get a disability claim filed properly and benefits paid quickly.

A publicly traded insurance company reports to the stockholders, not its insureds.  Even mutual companies construe their attacks as simply defending the interests of their policyholders.  The most important numbers aren’t your rightful disability benefits —  it’s their bottom line.  Claim departments in insurance companies have the resources to come up with excuses to deny otherwise valid claims.  Don’t let yourself become one of their victims.  If you have questions, please visit our FAQ page.  For more information on obtaining help for your claim, check out our services.