Long Term Absence and Permanent Health Insurance

[alef]

Long time now write but never a peaceful moment is there!

 

Almost a year on from paying the Permanent Health Insurer is now stopping the claim so employers says no more money for me.

 

I am confused as to why I should suffer as after all I have a contract with my employer to pay this money and not with the Insurer?

 

Have questioned with employer who is to review but can anyone help me with my contract employment position?

 

thanks again

[honeybee13]

Long time now write but never a peaceful moment is there!

 

Almost a year on from paying the Permanent Health Insurer is now stopping the claim so employers says no more money for me.

 

I am confused as to why I should suffer as after all I have a contract with my employer to pay this money and not with the Insurer?

 

Have questioned with employer who is to review but can anyone help me with my contract employment position?

 

thanks again

 

Hello again alef. I'm sorry to hear you're having problems again.

 

I think you need to do two things.

 

-check your employment contract to see what it says about sick pay. It could be that it provides for SSP only and then hands over to Unum.

 

-find out why payments have stopped. Some PHI policies pay out for a fixed period of 12 or 24 months. Or have Unum decided that you're 'better', for instance?

 

I checked this with OH who deals with this often and he thinks the same as I do.

 

Would you be able to check your employment contract, or maybe the sickness scheme if you have a copy and let us know please?

 

My best, HB

[alef]

Thanks,

 

My Employer says UNUM are driving this but have not given a reason for stopping the claim. My Employer has written asking for a reason stating that they have confirmed with me that no updated medical information has been requested by UNUM for many months now . My medical update is relevant as I have had further diagnosis and treatment ( that had been indicated to UNUM but not confirmed) since medical reports were last obtained and reviewed. Even without this there has been no dialogue to say that I was in fact fitter and therefore able to return to work. I am not being permitted access to UNUM wording I'm afraid.

 

Original contract of employment for my length of service gave 6months full pay, 6th months 75% pay. The old staff handbook made reference to Long Term Absence i.e. after a period of 12 months, and the fact that the company at its sole discretion could decide to make a claim under its ( the Groups) Long Term Disability Scheme. The current staff handbook does not show that this benefit exists but on questioning it was confirming that it did . HR knew little detail but in the end were able to confirm that I would need to sign a new contract of employment ( see earlier in the thread) . The parties to this new contract are my employer and myself . The contract itself is, in my opinion, ( not a lawyer but have seen a few contracts due to my profession) very very basic. it does make reference to the LTD scheme rules. It does not make any reference to UNUM in any way or even make reference to insurance or insurers anywhere in the document. It does make reference under the payment clause to the LTD scheme rules . These were supplied as a separate document at the same time as this new contract and the document bears the heading XXX (the name of my Employer) Long Term Disability Scheme. This document makes one reference to UNUM where is says the company has insured itself against risks of claims under the scheme and has employed UNUM to assist in assessing cases and that UNUM may require members to provide additional information concerning any claim. This is done under the Definition of Disability rule. Under this rule the words current occupation are used. Interesting that that contract states the need to satisfy the definition of incapability as set out in the rules. This word is not set out in the rules anywhere. My own thoughts are that sometime back when my employer changed from offering a self insured scheme vs insuring ,the two documents were not brought together well enough to state clearly what the intention is. This is what I want to prove so that my employer doesn't move to dismissal ( which was mention to me on the phone) when I say I am still not fit to return to work. Its too bad that they may no longer be insured. My body may be broken but my mind is not so I want to win this if I can ? Employer has also requested a meeting in two weeks time.

 

thanks to all

Edited November 3, 2011 by alef
did not make sense on re read.

[honeybee13]

Hello again, thank you for the extra information.

 

I think I see where you're going with this.

 

From the insurance perspective, I don't think I have a great deal to say without knowing what Unum are up to. As I said, some policies only pay out for a limited period, but HR don't seem to know whether this is the case or not. HR often don't understand insurance policies and companies can run rings around them on occasions. OH said you might have trouble accessing the policy wording and need to push hard to try to get it. Maybe people with different knowledge to me would have suggestions about that? Maybe a subject access request later?

 

From an insurance point of view, I'd say the 'current occupation' definition is in your favour. Otherwise they could say that you could carry out a different occupation and refuse to pay on those grounds.

 

My feeling is, and I would value input from anyone else who knows, is that if you became ill whilst with this employer, Unum should pay the claim as long as you meet the conditions of incapacity, and that there's no limit on the time they pay you. Unless you pursue and win your argument that the insurance policy isn't relevant.

 

I will ask OH later if he has anything to add. Btw, is there a broker involved, or are HR doing their own thing with Unum [and maybe not very well]?

 

My best, HB

[alef]

There is no broker involved.

[honeybee13]

There is no broker involved.

 

You're welcome for the opinion, alef .

 

It's a shame there isn't a broker who might fight your case, but HR could still do it if they want to. If Unum turn out not to be following the rules, I think I'm right in saying that you can still follow their complaints procedure and then go to the ombudsman afterwards, if appropriate.

 

But to take the insurance route, you need to know more about why the benefit has stopped.

 

My best, HB

[patrickq1]

ANYTHING COME OF THIS hONEY I WAS JUST READING ABOUT UNUM AND ASOS STINKS TO HIGH HEAVEN READ ON EXCERPS FROM PRIVATE EYE

 

 

MUTUAL BENEFITS

 

 

The American insurance giant has been very cosy

with successive British governments

 

Tricky questions are again being asked about the profits American insurance giant Unum stands to make from its massive media push on income protection cover, promoted as the answer to the latest tough welfare reforms.

 

Pulling stunts like persuading six bloggers to live for a week on the current average benefit of £95 and then write about it, Jack McGarry, chief executive at Unum UK (pictured), earlier this year warned: “The government’s welfare reform bill will seek to tighten the gateway to benefits for those people unable to work due to sickness or injury. Each year up to 1m people in the UK become disabled and the reforms mean that working people will be able to rely less on state benefits to maintain the standard of living they were used to prior to their illness.” Well, Unum should know. Behind the scenes it has been helping Tory and Labour governments slash the benefits of disabled and sick people for years – going right back to Peter Lilley’s social security “Incapacity for Work” reforms of 1994. Lilley hired John Le Cascio, then vice-president of Unum, to advise on “claims management”. Le Cascio also sat on the “medical evaluation group”, which – according to Professor Jonathan Rutherford in the academic journal Soundings – was set up to design and enforce more stringent medical tests.

At the same time, the UK wing of Unum was launching what it boasted was “a concerted effort to harness the potential” from predicted cuts in benefits, urging people to protect themselves with a “long-term disability policy from Unum”.

Eye asked first

The Eye first questioned Unum about the possibility of a serious conflict of interest back in 1995. Dr Le Cascio said he didn’t “feel that way” and wouldn’t have taken the government job if he thought there was a conflict. That, of course, was ten years before Unum was found guilty in the US of “systematically violating” insurance regulations and fraudulently denying or “low-balling” claims using phony medical reports, misrepresentation and biased investigations (see Ad Nauseam, last Eye).

Fast-forward 16 years, and plus ça change. Unum’s tarnished reputation has done nothing to diminish its influence here and the Department for Work and Pensions (DWP) is still denying there’s anything amiss about Unum’s more recent meddling. In a lengthy reply last month to Norman Lamb, Nick Clegg’s chief adviser, the DWP neatly skirted questions about whether Unum was advising on welfare reform and about its unlawful activities in the US.

Yet Unum executives sat on both the mental health and physical function “technical working groups” set up under the Labour government in 2006, which reviewed and finally came up with the new, stricter “work compatibility assessments”, introduced for new claimants in 2008. In fact Unum and Atos, the huge French outsourcing company that holds the government’s multimillion contract to conduct the widely criticised assessments on behalf of the DWP (see In the Back, last Eye), were the only for-profit companies represented on the groups. Unum chief executive McGarry has now been appointed to the expert panel reviewing the sickness absence from work system announced by the government in February.

Lobby styles

Prof Rutherford wrote that Unum had also been “building its influence” in a variety of ways over a number of years. He said that in 2001 Le Cascio was a key player at a ground-breaking conference at Woodstock near Oxford, titled “Malingering and Illness Deception”. Malcolm Wicks, Labour work minister at the time, and Mansel Aylward, then chief medical officer at the DWP, were among the 39 delegates.

In the same year, Unum launched a public private partnership to act as a pressure group to extend influence in policymaking. And in 2004 it opened the £1.6m UnumProvident Centre for Psychosocial and Disability Research at Cardiff University. (The centre has since been renamed and Unum says it no longer provides any funding – no doubt because of claims that academic integrity could be called into question by its influence.)

Unum has been lobbying, sitting on expert groups and hosting meetings at party conferences of all colours ever since. And lo and behold, in May this year, Unum’s then medical officer Prof Michael O’Donnell jumped ship to become chief medical officer at Atos. He barely had time to catch his breath before giving evidence to the Commons committee looking at the welfare reform bill.

But Unum is once again denying any conflict of interest “since our current work with the DWP and our marketing campaign are different.” It said its current consultation work is about helping people return to work and its advertising campaign was educational and does not support tightening benefit changes.

Meanwhile disability activists who have fallen foul and been forced to appeal cuts in DWP benefits based on flawed Atos assessments, and campaigning groups like Black Triangle, think the whole thing stinks and are urging MPs to investigate

[alef]

Have read this type of article before. As you say both UNUM and ATOS are out to stop paying benefits.

 

I in the spirit of the forum am fighting on and obtaining the medical reports that are evidentially required to allow UNUM to reconsider this matter.

[alef]

Hi

 

Me again, awaiting a decision from UNUM my Employer having asked them to reopen the case and review.

 

Meantime meeting with my Employer who want me to tell them what I feel I can do in the workplace. This is a nightmare as I feel that unless I lie and agree that I can do all the tasks I did before then they will try to dismiss me on the grounds of cabilitites ( or lack of them) .

 

Alef

[honeybee13]

Hello again. I'm sorry to hear you're still having problems.

 

Can you give us an idea of what work you used to do please?

 

My best, HB

[alef]

Unum have upheld their original decision to cease paying the claim . They say they have assessed the claim again the Defintition C test of incapacity which is that alef due to illness or injury is unable to perform the material and substantial duties of his/her Insured Occupation and is unable to by reason of illness or injury to follow Any Occupation for which she is reasonably fitted by reason of training, education or experience.

 

Employer has provided this response and I now have the opportunity to present to the decision makers responsible for my Employers long term disability scheme to say why I think I still meet the definition of incapacity. Before I do this very very challenging thing I am still not sure that the definition used the documents that are the contract between my employer and I means the same as the Unum one. The definition of disability contained in these documents says that a claim will only be admitted if by reason of sickness you are unable to perform the material and substantial duties required of you in your current occupation and there is no reasonable alternative occupation which you are suited and which you can perform.

 

Is Insured Occupation the same as current occupation or does is it insurance speak for the category of employee and that the actual cover is about me being unable to do any occupation.

 

The category of occupation I held I would consider to be as non manual qualified professional with corporate client responsibilities. Core competencies as you might expect, senior level technical experience and professional knowledge, strong communication, strategic, negotiation skills.. This skill set albeit a little rusty remains intact. It is the every day required functional capabilities of walking, standing, sitting that are limited in terms of lack of ability and consistency of ability before low level pain increased to the point of flare up of upper limb and back pain. Pain and ability of movements can be further increased and limited where additional functionalities are added e.g. sitting typing, reading, holding a telephone. I have unable to withstand load beyond very very light pressure without suffering consequential flare up ( assuming the load is attemptable in the first instance). This is a result of conditions I have listed earlier and all medical advice is to continue with pain management strategies , analgesic pain relief, biannual specialist injected pain relief, pacing, cognitive behaviour therapy, physiotherapy. I am encourage by pain clinicians to be positive about what I can achieve and that none of us know how things might be going forward.

 

I hope that there is a way through this .

Alef

[honeybee13]

Hello again.

 

I would be arguing against the terms of the policy rather than what your employer says. I would expect Unum to use their own wording. That's the contract in force between them and your employer. I'm a bit confused about this:

 

They say they have assessed the claim again the Defintition C test of incapacity which is that alef due to illness or injury is unable to perform the material and substantial duties of his/her Insured Occupation and is unable to by reason of illness or injury to follow Any Occupation for which she is reasonably fitted by reason of training, education or experience.

 

I read that as if you meet definition C, as in being unable to do things, or are you saying that they think you are 'able' to meet the criteria above?

 

Have you spoken to the FSA at all? They have a helpline that you can ring about problems you're having and if you persist a little, I hope you'll be able to find someone with specialist knowledge of PHI/PDI insurance.

 

Ultimately, if you don't like Unum's final decision, this is where you are likely to end up, the FSA and the ombudsman.

 

My best, HB

[ajs444]

Having problems with UNUM myself, can I bypass FOS and proceed to Small Claims Court?

[honeybee13]

Having problems with UNUM myself, can I bypass FOS and proceed to Small Claims Court?

 

Hello ajs. I don't know the answer to that. You might try posting in the legal forum.

 

My best, HB

[caro]

Having problems with UNUM myself, can I bypass FOS and proceed to Small Claims Court?

 

Anyone can go to court as long as they follow the CPRs. It's likely to be a lot quicker than FOS.

[ajs444]

Going through Scottish Courts, already have 2 cases with FOS, would be just as well writing to Santa.

[alef]

What happens now? Employer saying after review they agree with Unums decision but they are not as Employer saying that they think I am unable to do my old job but that I am able to work in some capacity. Difficulty for me is that my Employer saying they don't have a job for me. So probably going to be dismissed this month!! Unum have acted badly in my case and having received copy of complete file ( remember that one guys you can get the file free if you write to their data protection officer) I know where I would like to challenge them. What are the various ways, earlier thread talked of court and CPRs ( what are they) ?

 

Thanks all

 

Alef