Recent Updates:
07/24/08 - Response to question in guestbook -- Yes, thetsascam has informed Dr. Allen Woolf and other Cigna executives of the case on this site and the website itself. (Emails to Cigna) No response has been received.
07/13/08 - We have uploaded the 15 item final appeal and related adverse determination letters associated
with the case study to illustrate the inconsistencies between Cigna's statement from Dr. Woolf to ABC's Good Morning America and the reality of what claimant's are suffering
through when dealing with Cigna. The documents are located at the bottom of the rehabilitation counselor section . The claimant was denied benefits after ten years of receiving benefits and while recovering from his twelfth surgery following a free fall elevator accident. The denial was received just two weeks into a painful eight week post surgical rehabilitation program following that twelfth surgery.
07/10/08 - CIGNA's chief medical officer, Dr. Allen Woolf, issued a statement in response to Good Morning America's expose. IT IS COMPLETE BS!!! All you have to do is read the the case study on this site. CIGNA did everything but follow the guidelines presented by Dr. Woolf. They missed deadlines, delayed, used in-house doctors and counselors to overturn the opinions of independent experts, lied to the claimant about record requests, discarded four days of surveillance because it did not support benefit denial, discarded a Social Security determination even though contract definition of disability was essentially identical to SSDI, employed selective review and sought denial after ten years of paying benefits right after CIGNA lost the disability contract at the claimant's former employer. Good Morning America needs to challenge CIGNA and Dr. Woolf. The case study on this site clearly indicates CIGNA does not follow the guidelines outlined in Dr. Woolf's statement.
07/09/08 - ABC's Good Morning America did an expose on Cigna's disability claim practices. Here is the link to the story "Denied: Fighting for insurance coverage" ------make sure you read the comments at the end of the article. Cigna looks like it is headed down the same path as Unum years earlier since the Unum disability settlement was born out of a similar television expose.
06/21/08 - The Supreme Court has ruled in Met Life v. Glenn in the claimant's favor. This should make insurers like Cigna take heed when they benefit from a favorable Social Security decision (offsetting payments) and then deny benefits as Cigna did in the case study on this site. More information is available on Scotusblog and Scotuswiki
05/20/08 - A whistle blower lawsuit has been filed against CIGNA Group disability. The hits just keep on coming. Here is The New York Times article.
05/01/08 - The CRCC has recently published an advisory opinion associated with the Case Study on this website. It is 11-07 (2). You will note this was a post hoc advisory opinion born out of an ethics complaint filed with the CRCC. The CRC's "unethical" work product had already been used by the Insurance Company to deny benefits. The advisory opinion is essentially a published version of a "letter of instruction" sent to the CRC and a "cease and desist" order issued to the Insurance Company (CIGNA/Intracorp) in November of 2007. The CRC and Insurance Company have ignored the adjudication. The claimant is still denied benefits.
04/16/08 - Judge blasts claim handling and vocational analysis in Crider v. Highmark - "The report's superficial "analysis" can not withstand scrutiny". TSA failed to take into account side effects of Oxycontin.
04/14/08 - Another in-house Life Insurance Company of North America (CIGNA) transferable skills analysis tossed by a judge citing "the court has found that the TSA was predicated on an unreasonably selective view of the available medical evidence"- Juszynki v. LINA - Does anyone know who the appeal team manager was? The judge saw right through the insurer's selective claim review scheme.
........Gary Person, Appeal Team Manager, Cigna presented at the Chicago Claim Association (Midwest Claim Conference) in May. Anyone think he discussed the case Combe v. Life Insurance Company of North America (CIGNA Subsidiary) or his involvement in the case study at THETSASCAM? The brochure mentions he is an "experienced attorney". That's news to many of us since he never revealed he was an attorney. We will post some correspondence between Gary Person and the claimant in the case study on the rehabilitation counselor page. Very slick indeed.
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THE TRANSFERABLE SKILLS ANALYSIS SCAM
Certified Rehabilitation Counselors (CRC) - The Insurance Industry's "Hired Gun" performing transferable skills analysis in disability claims? Has the CRCC let the Insurance Industry have their claim denial cover?
Transferable Skills
Analysis (TSA)- The Insurance Industry's
"weapon" in disability claims? There are no studies supporting
the effectiveness of Transferable Skills Analysis with input solely from an Insurance Company? A transferable skills analysis prepared with biased input is
a crooked and unethical enterprise according to the Commission on Rehabilitation Counseling Certification (CRCC):
The methodologies for performing TSA's have not been
independently tested and TSA's are not considered scientifically
reliable. A Transferable Skills Analysis report is a useless tool if it is not
accompanied by ethical standards for input and a labor market survey. The
fact that Insurance Companies and Certified Rehabilitation Counselors use these
scientifically unreliable TSA's to render claims decisions is risky, unethical
and borders on being dangerous.
There are numerous methodologies used to perform a transferable skills analysis
however none of them can correct for poor data collection, poor data input,
unethical behavior, financial incentives to produce a result for the insurer,
selective review and bias. There isn't a single academic in the
rehabilitation counseling field that would make the claim that a transferable
skills analysis, with input solely from an insurance company, is an empirically
supported "reliable" methodology. Certified Rehabilitation
Counselors that engage in and endorse this type of scientific bias act in
contravention of their ethical charge to the disabled person (client).
If a Rehabilitation Counselor is asked to review
a disability case for an Insurance Company the claimant should be very
worried. These Rehabilitation Counselors are not your friend. The Insurance Industry goes where they think they will get the
result they desire. That usually leads the Insurance Industry to the
CRC's inclined to stretch the boundaries of their competence and the limits of
their ethical obligations. The Insurance Industry knows that they only
need a small number of ethically challenged Certified Rehabilitation Counselors
to do their dirty work. One hundred ethically challenged CRC's out of
some 16,000 can save the Insurance Industry 100's of millions of dollars in
claims.
The Insurance Industry is fully aware of the fact that
different results can be achieved with selective input. The problem is
the body charged with overseeing and certifying certified rehabilitation
counselors has done little to to establish or adopt TSA standards and to stop this ethical rot amongst their
certificants. That leads one to believe the unholy alliance between the
Insurance Industry and CRC's comes with a wink and nod to keep the referral money flowing. The words
"skills" and "analysis" have nothing to do with the goals
of a "Transferable skills analysis". It's all about money and
denying claims.
The Insurance Industry knows their reputation rates the
equivalent of a used car salesman on the trustworthy meter. By partnering
with Certified Rehabilitation Counselors they can cover themselves with the CRCC Code of Ethics when they
deny claimants their benefits. Unfortunately, what typically happens is the
Insurance Industry, driven by its greed, demands more and more ethical concessions from CRC's to justify additional referrals. A cycle of
dishonesty is born, the CRCC Code of Ethics is rendered a sham and the person
with disabilities ends up in the cross-hairs.
The CRCC Code of Ethics must be tightened. All CRC's
should be on equal footing. Right now the Code of Ethics contains far too
much gray area regarding TSA's that allows ethically challenged CRC's to game it for their own
financial gain at the expense of ethical Rehabilitation Counselors who genuinely care about folks
with disabilities (Clients). The rehabilitation counseling profession has
a real problem and it needs to be addressed.
The Rehabilitation Counselor Ethical Dilemma:
Certified Rehabilitation Counselor's (CRC's) must decide whether their Code of Ethics has meaning or if they have let the Insurance Industry render the CRC designation a sham. This website is dedicated to exposing how one of the Insurance Industry's favorite tools, the transferable skills analysis (TSA), is unscientifically used to deny disabled individuals their hard-earned earned ERISA benefits. The first case study is located under the tab "case studies" and it should raise the following questions:
1. Why hasn't the CRCC instituted or adopted standards for performing Transferable Skills Analysis in ERISA cases similar to Social Security?
2. If TSA's can produce multiple results in ERISA cases using multiple methods why is the rehabilitation counselor profession and the CRCC passing it off as a valid assessment tool? Are TSA's junk science masquerading as real science?
Certified Rehabilitation Counselors (CRC) play a very
important role in our society however a number have potentially
besmirched the profession by selling their professional designation to
the Insurance Industry despite being ethically charged with objectively
evaluating their client, defined as the disabled person. This web
site will endeavor to illustrate how some rehabilitation counselors may be
letting themselves become pawns of the Insurance Industry. Far too many
ERISA disability cases are unnecessarily being forced into the courtroom due to
the unscientific preparation of a transferable skills analysis. Worse yet,
the weakest disabled individuals with too little resources to even reach a
courtroom, are being worn down in a rigged and sick game of dishonesty by an
Insurance Industry flowing with legal resources, shielded by a maze of ERISA - 29 CFR 2560.503-1- regulations and armed with their most lethal weapon ---unscientific TSA's prepared under the guise of "objectivity" and "expert
opinion".
This site is hoping that current or former ethical
rehabilitation counselors step forward to challenge and educate their
colleagues. The web site should serve an additional resource to the
rapidly diminishing ranks of attorneys who are currently fighting the
Insurance Industry's ERISA claim denial machine. The time has come to
awaken State Regulators and Attorneys to the deceitful claim processes
utilizing "pay to play" transferable skills analysis reports.
Background Items Of Interest:
Rehabilitation counselors are ethically charged in their Code of Ethics with objectively evaluating their client (the disabled person), even in forensic settings. The Insurance Industry is not the client and never has been. Rehabilitation counselors should not allow themselves to be coached, prodded, directed or influenced by the Insurance Industry when preparing a transferable skills analysis in an ERISA setting. When rehabilitation counselors lose sight of their CLIENT they become pawns in a systemically rigged review that is unquestionably biased toward the Insurance Industry. CRC's should know that Congress did not promulgate the ERISA administrative process to be adversarial. Consistent with the CRC Code of Ethics the ERISA review is supposed to be "full", "fair" and "objective".
The
Committee considered a request for an advisory opinion with regard to two
dilemmas with the first pertaining to the appropriate course of action to take
when there are conflicting opinions about a client’s ability to return to work,
as determined by a treating physician and a physician conducting an IME.
The Committee responded that it would be outside of the scope of practice of a
CRC to determine which set of restrictions or recommendations apply.
Further, a CRC would need to limit or discontinue services until the conflict
is resolved so as to be able to recommend and conduct appropriate job placement
activities that are not harmful to the client. Should such a situation
arise, the CRC would need to inform the client of the conflict and disclose to
the client the need to alert the referral source so that the conflict may be
resolved. The client should also be advised of any limitations, delays or
discontinuation of services. (A.1.c., A.3.a., D.1.a.)
The CRC
code of ethics states - Rehabilitation counselors will practice only within the
boundaries of their competence, based on their education, training, supervised
experience, state and national professional credentials, and appropriate
professional experience. Rehabilitation counselors will demonstrate a
commitment to gain knowledge, personal awareness, sensitivity, and skills
pertinent to working with a diverse client population. Rehabilitation
counselors will not misrepresent their role or competence to clients.
CRC Ethical Advisory 06/02
(4) states - The Committee considered a request for an advisory opinion as to
whether it is appropriate that certificants do not request information from
medical service providers when developing a vocational plan. The
Committee responded that a CRC who lacked current medical information would be
unable to develop a vocational report because
they are unqualified to render an opinion about an individual’s ability to
return-to-work or about their functional capacities absent such
documentation from qualified service providers. Furthermore, requiring
that individuals prepare vocational reports without the use of information from
medical service providers appears to be inconsistent with Federal and state
guidelines. (A.1.c, D.2.a)
The
majority of research conducted on TSA software has focused on ease of use and
whether these programs accurately assess transferable skills and earning
capacities. To date, no research has examined whether these programs
identify occupations that actually exist in the labor market.
Despite the
widespread use of these programs by vocational specialists and the reliance
insurance carriers place on information generated by these programs to award or
deny disability, it does not appear that use of these programs alone will
withstand a Daubert challenge. A traditional labor Market Survey of
employers should be conducted to determine whether occupations identified by
the software actually exist within a certain labor market.
1. Ability to remember locations
and work procedures
2. Ability to understand and
remember very short and simple instructions as well as detailed instructions
3. Ability to carry out simple
and detailed instructions
4. Ability to maintain attention
and concentration over extended periods
5. Ability to perform activities
within a schedule, maintain regular attendance, and be punctual within
customary work tolerances
6. Ability to sustain an
ordinary routine without special supervision
7. Ability to work in
coordination with and proximity to others
8. Ability to make simple or
complex work decisions
9. Ability to complete a normal
work day or week without interruption from psychologically based symptoms and
to perform in a consistent pace without unreasonable rest periods
10. Ability to interact
appropriately with peers and supervisors, including accepting criticism about
work performance
11. Ability to respond
appropriately to changes in the work setting, including potentially hazardous
conditions
12 Ability to travel to and from
the workplace or to alternative work settings with private or public
transportation
For example, a recurring problem
in private practice is the fact that it is often the insurance carrier or
self-insured employer who hires a rehabilitation counselor to provide services
to an individual who suffered a loss. This approach may lead to situations
where the financial concerns of the “customer” are in direct conflict with the
best interest of the “client.” According to the Code, the client’s interest
must come first, even at the expense of the customer. Doesn’t sound very good
for business, does it?
Nevertheless, if we examine a sampling of the Standards of Ethical Practice
from a business perspective, I think you will see that diligent conformance to
the Code’s mandates would always be good for business.
Adhering to the Code can have an immediate financial impact on your business.
Demonstrating that you adhere to a consistent code of professional ethics can
result in a reduction in your liability insurance premiums. Carriers who know
practitioners are subject to oversight and peer review of their professional
conduct by an objective organization, such as the Commission on Rehabilitation
Counselor Certification (CRCC), can offer those individuals a lower premium
because claims experience show the insurer’s liability exposure will be
reduced.
Another advantage is what I call the “level playing field.” In other words,
practitioners who follow the same code of professional ethics are required to
operate their business according to the same high standards of conduct. (No
bushwhacking allowed.)
The Code requires that the counselor’s primary obligation be to the client. The
referral source must be informed of this, which allows the counselor to avoid
possible conflicts with a payer by indicating upfront that the client’s
interest must come first. From a business standpoint, it’s always best to avoid
potential misunderstandings instead of trying to clear them up after the fact.
The irreducible logical core of finding that a
claimant is capable of performing alternative occupations is a finding that
claimant has a residual functional capacity that equals or exceeds the
functional requirements of a feasible alternative occupation. These two
determinations – the claimant’s capacity and the occupations requirements –
must together be detailed enough to make rational comparison possible.
Otherwise, the finding that the claimant can perform alternate occupations is nothing
but a bald assertion.......
