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 Battling with long-term care insurance company 
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Joined: Thu Jul 03, 2008 11:05 am
Posts: 150
Location: Raleigh, NC
Post Battling with long-term care insurance company
Has anyone successfully appealed an insurance company's denial of benefits?

My mother took out a policy for nursing home care when she retired 20 years ago. Some of the wording about what it covers is ambiguous. It clear states that it covers dementia care, but it is denying her a 100% benefit because she is not in skilled nursing. She is in a licensed dementia care facility -- with the only license North Carolina gives for dementia care -- but it describes its beds as assisted living, as does nearly ever other dementia care facility here. In fact, in all of Wake County only two facilities list dementia beds (a grand total of 32) as nursing care.

We appealed the company's decision and were denied a second time. Our next step is complaint to the state Department of Insurance.

If anyone has experience or tips that might be useful, I'd appreciate hearing about it.

The company has granted us a 50% benefit. That's better than nothing, but her care is extremely expensive, and we feel she deserves the benefits she paid for all these years. A doctor would probably sign for her to go into skilled nursing, but we don't want to move her if at all possible. She is used to where she is, we really like the care managers, and it's far more convenient for us than the two places that have nursing/dementia care.

Garnet


Thu Sep 11, 2008 2:20 pm
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Joined: Fri Aug 11, 2006 1:46 pm
Posts: 4811
Location: SF Bay Area (Northern CA)
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Garnet,

I think most of the LTC policies until very recently were limited to SNF care. ALFs are rather new types of care facilities.

I'm not sure you will be successful upon appeal but it can't hurt to try. I'm amazed they are even paying out at 50%!

I think your petition should be based on these facts:

* it's cheaper for the insurance company to have her in an ALF rather than a SNF (I'd call the nearest dementia-capable SNF and get their cost figure.)

* she needs the care that an ALF can provide (Indicate what level of care she's on there.)

* the dementia-capable SNF is further away for family

* it's best not to move a dementia patient

I don't know if your mother is like my parents and grandparents but my relatives would move to another facility without question if this saved them money.

Good luck,
Robin


Thu Sep 11, 2008 3:19 pm
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Joined: Sat Oct 27, 2007 9:16 pm
Posts: 165
Location: tennessee
Post ltc
Same problem. Spouse's policy is pretty clear, I just didn't notice it before. Only when we received the first check after the 90 day waiting period. By then, he had finally begun to adjust, and I just couldn't move him. I've been told that he will have longer coverage since he's not using the full amt of the daily benefit, but he probably won't live that long. His policy pays 80% and we pay the rest. At least we'll get to deduct most of that $900. If you do a successful appeal would love to hear about it.

_________________
Would have despaired...


Thu Sep 11, 2008 3:33 pm
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Joined: Thu Jul 03, 2008 11:05 am
Posts: 150
Location: Raleigh, NC
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Wow. Thanks for such fast replies.

One of the reasons we think we may have a shot at the appeal is that the company is paying 50% -- the policy doesn't even mention that option but we're not pointing that out. That 50%, though, is 50% of the benefit, not 50% of the cost. Even 100% of the benefit will cover only half the cost -- there's a $100 per day cap. So unfortunately, we can't make the claim the company saves money by paying.

I'll keep everyone posted as we go through this. Filing with the insurance department is free and we can do it ourselves so there's nothing to lose.

Meanwhile, if anyone else has tips, I'm all eyes and ears.

Garnet


Thu Sep 11, 2008 3:52 pm
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Joined: Fri Aug 11, 2006 1:46 pm
Posts: 4811
Location: SF Bay Area (Northern CA)
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Garnet,
When you get a LTC policy for yourself, you'll know that you need to have a daily limit that increases with inflation or by 5% a year. Of course $100/day doesn't cover much of anything these days.
Robin


Thu Sep 11, 2008 4:01 pm
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Joined: Thu Jul 03, 2008 11:05 am
Posts: 150
Location: Raleigh, NC
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Oh, yes, I'm learning a lot about what I need to be prepared for a few years hence, and it's scaring the life out of me. GB


Thu Sep 11, 2008 4:04 pm
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