Washington, DCOne tactic that Unum Provident employs to deny countless Unum long term disability claims is to invoke the pre-existing conditions clause--usually defined as any health condition you already have --including an injury that happened prior to the effective date of the insurance--when you enroll in a health insurance plan or policy. Or Unum Provident may deny health insurance altogether due to a pre-existing clause—and that may be a federal offence.
For instance, individuals cannot be denied health care coverage for a medical condition as a result of a genetic marker for the condition. The Health Insurance Portability and Accountability Act (HIPAA) clearly forbids a group health insurance plan, including Unum Provident, from using genetic information to establish rules for eligibility or continued eligibility.
Unum's long term disability income protection insurance plan says you have a pre-existing condition if:
- You received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 12 months just prior to your effective date of coverage; or
- You had symptoms for which an ordinarily prudent person would have consulted a health care provider in the 12 months just prior to your effective date of coverage; and
- The disability begins in the first 24 months after your effective date of coverage; unless you have been treatment-free from the pre-existing condition for 12 consecutive months after your effective date.
However, Unum often practices bad faith when it comes to pre-existing conditions: it denied Cheryl W. long term disability (LTD) claiming she had a pre-existing condition, even though her claim was clearly a work-related injury!
"I suffered a back injury in 2003," Cheryl says, "and in 2004 I received LTD payments from Unum. In the meanwhile, my company laid me off. In July 2004, my condition improved so much that I looked for, and found another job. I started working in August against my physician's advice and at the same time I informed Unum Provident, and they stopped payments.
"I got a new LTD policy with my new job, again with Unum. Within 6 months after termination of the previous LTD payments, my back problem returned and I asked Unum for LTD payments. However, Unum does not see this disability as a continuation of the previous case; instead they consider this a pre-existing condition. This way of acting punishes the honest (I voluntarily tried to work again, could have collected benefits longer otherwise). This policy is one-sided, and takes unjust advantage against the customer, de-motivates employees, and does not leave a real chance to get back to work…"
Unum continues to practice bad faith despite getting its knuckles rapped to the tune of countless lawsuits, mainly settled out of court.
Unum has been found guilty [Decision and Order of Insurance Commissioner Upon Settlement, File No. DISP05045984, DISP05045985, DISP05045986] of the following:
- Including language in group policies that excludes coverage for pre-existing conditions "caused by, contributed to [by], or related to the disabling condition" or for "symptoms for which diagnostic treatment was performed or symptoms for which a prudent person would have sought treatment," so that a disabling condition would not have to have been diagnosed, treated or even in existence during the policy's pre-existing condition period for it to be excluded from coverage;
- Misapplying the "pre-existing condition" clause to deny meritorious claims, e.g., characterizing obesity as the pre-existing condition for a previously asymptomatic, undiagnosed and untreated musculoskeletal, cardiovascular, peripheral vascular, pulmonary or orthopedic disability...
You Can Get Help
Both federal and state governments protect individuals from unreasonable denial of health insurance benefits for pre-existing conditions. In 1997, the HIPAA, or Health Insurance Portability and Accountability Act, was passed by the federal government to protect consumer rights with regards to pre-existing conditions for health insurance.
The HIPAA limits the time that an insurance company can deny benefits to a policyholder for pre-existing conditions for health insurance: this time period is typically between 12 to 18 months after the date a policy becomes effective. After this time, the HIPAA requires that a person be covered for pre-existing conditions.
If Unum Provident has unreasonably denied benefits for pre-existing conditions for health insurance, you may wish to seek legal help--laws regarding pre-existing conditions for health insurance are complex and can vary by state. An attorney will ask you to have all the documentation on which Unum is basing its decision. As well, gather all medical information you have that might prove the pre-existing condition had resolved and therefore would not be grounds for their denial.
A health insurance attorney can help determine if Unum Provident has acted in bad faith by denying pre-existing conditions, and more.