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Maine.gov > PFR Home > Insurance Regulation > UNUMProvident Multistate Examination/Settlement Agreement

Exhibit 4

Improved Procedures for Evaluating Multiple Conditions or Co-Morbid Conditions


1. Guiding Principles (see also UnumProvident Clinical, Vocational, and Medical Services Statement Regarding Professional Conduct)

Benefit Center professionals will evaluate all data available regarding a claim
            Both objective and subjective
            Both supporting impairment and supporting capacity


Benefit Center professionals will consider and afford appropriate weight to all diagnoses and impairments, and their combined effect on the whole person, when evaluating medical data in a claim file.

Where multiple conditions or co-morbid conditions are present, each medical
professional and all other Benefit Center professionals evaluating the claim share
responsibility to ensure that all diagnoses and impairments are considered and
afforded appropriate weight.

When multiple medical professionals review a file, each medical professional and all other Benefit Center professionals share responsibility for coordinating their opinions and ensuring that each understands how the various opinions fit together in a coherent view of the claimant’s medical condition, capacity, and restrictions/limitations.

2. Changes in procedures


Several techniques will be used to ensure that claimants with multiple conditions are fully and fairly evaluated regarding the totality of their limitations. These alternatives include

  • Designated clinical consultant in each impairment unit to receive and manage consultation requests from other units
  • Access to multi-disciplinary meetings to consider totality of impairments
  • Referral to generalist or primary care physician (internist, occupational physician, or family practitioner) to consider effects of all conditions on overall function and limitations

    Each of these techniques is currently in use at two or more locations, and all locations
    use at least two of these techniques.

    A Medical Analysis Checklist (see format below) has been developed as a tool for Benefit Center professionals. The checklist should be used when multiple on-site physicians have reviewed a file, and is available as a tool for organizing a whole person analysis of impairments for any claimant.

3. Training

Clinical, Vocational, and Medical Directors at each claim processing location will identify areas for company-sponsored continuing nursing and physician education.


Medical Analysis Checklist

The checklist may be useful at several points during a claim, including liability determination, change of definition, and contemplated claim closure. It provides a “snapshot” at a particular point in time of all recent treaters, diagnoses/syndromes/problem areas identified, restrictions and limitations arising from each, and our contractual assessment of those restrictions and limitations.
For illustrative purposes only, an example is offered below on how the form might be used.


Claimant: _Jeff Styles_________       Soc Sec #: _345_-_67_-_8912_       Date: _8_/ 11 /_2004_

Physicians Consulted
In Last Year
Diagnoses or
Syndromes
Restriction
Identified
Limitation
Identified
Assessment
Physician Date
Last
Seen
       
           
Thos. Moore, MD 7/9/04 1. Cardiomyopathy   Sedentary work only Mr. Styles’ insured occ as foreman required frequent walking; at change of def we have identified gainful sedentary positions in his region
      Must be able to elevate feet above chest 10” every hour   Voc reports this is an accommodation permitted by most employers, and confirmed by those offering gainful positions
      No lifting over 10#   Available in gainful positions
    2. Atrial fibrillation No work near microwaves or large electrical power sources due to implanted defibrillator No lifting over 20# Available in gainful positions
Roger Grise, PhD 6/7/04 3. Depression   Impairments in interpersonal relations; concentration; deep pessimism Dr. Grise reports depressive symptoms have remitted; GAF now 72; limitations considered resolved per OSP assessment of 7/29/04; Dr. G agrees per letter of 8/4/04
James Fisher, MD 4/12/04 4. Fatigue No prolonged standing or walking (>30”); requires variable schedule and up to 1 hr of rest per 4 hrs worked   Re-conditoning via PT improved endurance as of 7/29/04 per Dr. Liu
Frederick Liu, MD 5/7/04 5. Diabetes mellitus Regular meals; no overtime; needs regular schedule   Gainful occupations permit regular hours
    6. Epilepsy     Never asserted as cause of disability; has been well controlled since 1993 by medication
    7. Chronic pain (fibromyalgia)   Cannot work more than 2 hrs daily Through cog-behav program delivered through Dr. Grise, Mr. Styles has improved his conditioning and attitude and now reports he is ready for a gradual RTW. Dr. Liu concurs and will manage rehab program


Last Updated: August 22, 2012