Haims: When long-term care insurance companies deny a claim | VailDaily.com

Haims: When long-term care insurance companies deny a claim

Judson Haims
Valley Voices

Long-term care insurance is not 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.

Long-term care insurance pays for services that are not covered by private health insurance and sometimes not 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 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 claims, refuse 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 long-term care policyholders who have run into trouble when attempting to open claims. Sadly, this is a big problem.  

Last week, I received a call from the daughter of a past client. Since February, she has been fighting with her parent’s long-term care insurance provider to open a claim for her father. Her folks bought 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 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 of the person you spoke with. When communicating in writing, always try to use 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 a 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, per the policy, it would not provide benefits until her father was deficient in at least two activities of daily living. Incredulously the daughter informed them that the established care plan clearly identified that he was deficient in four of six activities of daily living and should therefore certainly meet their requirement.

While there are more, six generally recognized activities of daily living 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 provider was conducting its business in such a questionable manner, I put the daughter in contact with the office of the state insurance commissioner. 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 to the family for the services they had paid for out of pocket.

Undoubtedly, long-term care insurance can be a wonderful thing, and thousands of policyholders 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 a policy or needing to open a claim, make sure you understand the following four elements of a long-term care insurance policy:

  • What is covered by the policy and what isn’t?
  • What is the daily/weekly amount of coverage?
  • What are the terms/qualifications for opening a claim?
  • What is the elimination period? The elimination period is often described as the amount of time that must pass after a claim is opened before you start receiving reimbursements.

Judson Haims is the owner of Visiting Angels Home Care in Eagle County and advocates for our elderly. For more information, go to visitingangels.com/comtns or call 970-328-5526.