Denied Insurance Claims

Last month’s column focused on the need to protect one’s earnings with disability insurance during the income producing years; and long term care (LTC) coverage to protect one’s nest egg during the retirement years.  Even though a person may have disability or LTC insurance, the definitions, exclusions, limitations and benefits will determine under what conditions a claim would be payable.  Be sure to review any policies definitions, exclusions, limitations and benefits when considering the protection you need.
This column will focus on a denied LTC claim.  LTC policies define the “triggers”, in their benefits provision, which state under what conditions benefits would be payable.  Be sure to examine the definitions of the triggers carefully.  Why?  Keep reading.  This is an actual case.
A 75 year old has dementia.  While she does relatively well, she has made irrational decisions over two years.  She lives in an assisted living facility due to her need for care.  In the mid 1090s, well before any health problems, she secured a LTC policy to help pay for LTC needs such as a nursing home stay or assisted living.
Her policy has some uniquely restrictive triggers for claim.  First, the policy requires “continuous 24 hour care” to pay on a cognitive disorder.  To meet this requirement, one would probably need to be in a secured LTC unit.  In this case, this person is able to get out, but mostly with family and friends.
The other triggers to allow for payment due to a person needing help with activities of daily living (ADLs) are also restrictive in this policy. Commonly one of the areas a person may need help with is bathing.  This policy does not include bathing as a trigger.  Therefore, a need for assistance with bathing does not make a claim payable.  For two years claims have been filed against this policy in an attempt to secure payment of the assisted living facility.  For two years those claims were denied as this 75+ year old did not present information for payment based on these policy triggers.  (Bathing is needed by this person and performed, but it is not a trigger for a claim to be payable under this policy) It would be easy to just give up, but allow me to further explain what happened form here.
First, it cannot be shown this person has 24 hour continuous care even though she has moderate dementia.  However, she is incontinent and that meets one trigger to present an ADL claim.  To present a payable claim, she must present a second trigger.  The other triggers are transferring, feeding, dressing, toileting.  To make a claim payable, she would need to meet the definition of one of these triggers.  Reading the definition of toileting; the last line states “Your ability to get on and off the toilet and maintain a reasonable level of personal hygiene including caring for clothing”.   Therefore, in our opinion, if she needs her clothes laundered by the facility after toileting, she may qualify for assistance from this toileting trigger.
After research and a thorough review of medical records and a meeting with the facility it was determined that she was in need of having her clothes laundered by the facility after toileting.  We presented this claim using the triggers of continence and toileting.  We sited in her facility records including her plan of care to show the laundering of soiled garments by the facility.  Three weeks later the family was notified that this claim will be now being paid.  This benefit amount to be paid is $3,500 a month.  This benefit will continue for 6 years.
The lesson here is not to give up. Be sure to secure professional help when buying any insurance policy.  Read the outline of coverage and the policy.  Look for the provisions stating benefit definitions, limitations and exclusions.  Seek professional help when it comes claim time.  This help may save you and your loved one thousands of dollars and a whole lot of stress.