Judson Haims: Options for when long-term care insurance companies deny or won’t pay claim
Special to The Aspen Times
Long Term Care Insurance (LTCI) is not an insurance most people know much about. Considering that we all will reach a point in life where we will need some type of long-term care, it might be worth looking into.
LTCI is an insurance that pays for services that are not covered by private health insurance and sometimes, neither by Medicare. It pays for both medical and non-medical services that aid individuals who are unable to take care of themselves due to prolonged ailment, chronic illness or disability. The care can be provided in a facility such as an assisted living facility or within a person’s home.
Although the insurance may be a good idea to help cover the expensive services involved in keeping a loved one as independent as possible, insurers who make it difficult to open a claim, refuses to pay them or besiege people in red tape are undermining the value of this insurance.
In recent years, we have been contacted by many LTCI policy holders who have run into trouble when attempting to open claims. Sadly, this has become a big problem.
Last week, I received a call from the daughter of a past client. Since February of this year, she has been fighting with her parent’s LTCI provider to open a claim for her father. Her folks bought long-term care insurance policies years ago and have paid its steep premiums ever since, but when her father needed benefits, the insurer had refused to open the claim.
In April, after repeatedly being stonewalled, she called our office and asked for assistance. Her father’s LTCI provider was using “delay tactics” by pretending they had not received faxed documents needed to open a claim. Fortunately, we were able to provide her time-stamped copies of all email and phone conversations along with fax documentation containing daily care notes of the services provided.
When communicating with an insurance company, it’s imperative that you document the time of your call and the name/ID of the person you spoke with. When communicating in writing, always try to use a fax so you can log the time and verify the documents were received. If mailing, send documents with a signature request verification.
About two weeks after the insurance company was sent the requested documents, they informed the daughter that they could not open a claim as they still needed copy of our state license. Once again, we provided them the license along with a fax log verifying that it had been sent months before.
In June, the insurance company verified receipt of all required documentation but told the daughter that as per the policy, they would not provide benefits until her father was deficient in at least two Activities of Daily Living (ADLs). Incredulously the daughter informed them that the established care plan clearly identified that he was deficient in four of six ADLs and should therefore certainly meet their requirement of being deficient in two ADLs.
While there are a number more, six generally recognized ADLs include: bathing, dressing, eating, transferring, toileting and continence. Her father was unable to bathe, dress, manage medication, prepare a meal, or transport himself to a grocery store to get food.
Disheartened to hear that the LTCI provider was conducting themselves in such a questionable manner, I put the daughter in contact with the state’s insurance commissioner’s office. Just about all insurance providers are regulated by this office. They are very effective in motivating insurance providers to act responsibly and will follow-up with you regularly until the matter is resolved.
I was relieved to hear last week that the insurance company finally opened the claim and reimbursed the family for the services they had paid for out of pocket.
Undoubtedly, LTCI can be a wonderful thing, and thousands of policy holders would tell you truthfully that their policy has been a lifesaver during their time of need.
I do not want to leave the impression that all providers act unethically. Most are responsible and want to help. However, when you encounter one that may be suspect, you must educate yourself of the details of your policy and have the fortitude to advocate for yourself.
When considering the purchase of an LTCI policy or needing to open a claim, make sure you understand the following four elements of an LTCI policy:
1. What they will/will not cover?
2. What is the daily/weekly amount of coverage?
3. What are their terms/qualifications for opening a claim?
4. What is the “elimination” period? (Elimination period is often described as the amount of time that must pass after a claim is opened but before you start receiving reimbursements.)
Judson Haims is owner of Visiting Angels Home Care in Aspen, Basalt, and Carbondale. He is an advocate for the elderly and is available to answer questions. He can be reached at http://www.visitingangels.com/comtns or 970-328-5526.
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