Insurance Frustrations

John1965

DW's LTC claim was approved back in November. So far I've only used it to pay for a cleaning service, but have finally found a caretaker who is able to give me a few hours of respite a few times each week. It's a good situation. But the LTC company wants reevaluations every four to six months. They are extremely stress producing for DW who is forced, unreasonably in my opinion, to revisit her diagnosis and to perform demeaning memory tests. It seems that only two purposes are served by these evaluations: making DW feel badly about herself and potentially having us say, "screw the claim, the pain isn't worth it." So frustrating. Additionally, my DW is on long-term disability through her employer. DW is only 57 and has been getting benefits for a full seven years now. The claim will pay until she turns 65. Her employer just changed vendors for administering the claim, and now I have to fill out more paperwork and have her doctor send a letter every six months. It just feels that the hoops to jump through are there only to trip us up to save them a few bucks. This disease is hard enough without artificial obstacles to care. The efforts and cash that go into denying claims should be spent on care.

Crushed

I have written an attorney letter on behalf  of a demented person  quoting three doctors who wrote that the condition was permanent and would end in death.  

  I wrote that any further  demand for testing was intentional  infliction of emotional  distress and would result in litigation  and reporting any physician involved to the appropriate authorities
Any inquiry from a non physician would be treated as the unauthorized practice of medicine  by a corporation

it Stopped   right there .
  

John1965

Thanks Crushed! Can I write the letter or do I need a lawyer?

Twin Mom

I wrote the same letter and they have left us alone since.  That's been 6 years ago.  I did not threaten the litigation part because if I were to sue the LTC provider it stops all payments until the suit is litigated.  I did however threaten filing complaints against all licensed people involved.

Crushed

Twin Mom wrote:

I wrote the same letter and they have left us alone since.  That's been 6 years ago.  I did not threaten the litigation part because if I were to sue the LTC provider it stops all payments until the suit is litigated.  I did however threaten filing complaints against all licensed people involved.

You go straight to the state insurance commissioner.  That is called an in terrorem clause  
 
 An insurer that is found to have acted in bad faith can be liable for damages in excess of the policy limits, including liability for judgments in excess of the policy’s limits, statutory penalties, interest, emotional distress, consequential economic losses, attorneys’ fees, and punitive damages. In bad faith cases, punitive damages are usually determined not solely with regard to what the insured’s actual losses were, but also with regard to the insurer’s wealth.

Twin Mom

So the policy actually states that....you are saying it is worth at least having a conversation with the Dept of Insurance.  I have always disagreed with how they calculate the per diem amount and when it is due, but have been terrified to ruffle too many feathers as we have a fantastic policy with no lifetime limits...but I am sick of jumping through hoops that I understood very differently when we bought the policy.

We just had our annual adjustment for the per diem amount.  It increases the per diem by 5% each year.  I also disagree with how that has been calculated...and over the many years of the policy it makes a huge difference.

Quilting brings calm

That bad faith language and mentioning the state insurance department really does work. Many years ago I was having issues getting an individual health insurance company to pay a claim. It was one excuse after another.  At the time I knew my insurance  terminology and I mentioned the bad faith claim settlement and the insurance department.  I got a call back that afternoon from a supervisor.  The claim was now paid. 

Crushed, I’ve forgotten the other terminology I used ( which may not apply here) but it had to do with the fact that the insurance company set the terms of the contract when they wrote the policy, and I had no choice in the matter,  it’s not like you can cross out a paragraph and refuse to accept it.  I don’t remember why I used it or what the exact wording is - but it did apply to my situation. Do you know the term I’m trying to describe? 

Crushed

It is called  a Contract of adhesion
 
 
https://www.law.cornell.edu/wex/adhesion_contract_(contract_of_adhesion)

Let me just note that all Long term care customers  are threatened by a scheme from the Pennsylvania insurance commissioner  to raise rates and reduce benefits to salvage insolvent companies.  Only one company is currently involved but the others are in the same situation.

https://insurancenewsnet.com/innarticle/regulators-split-on-plan-for-insolvent-pennsylvania-health-insurer

 

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Stuck in the middle

Victoria, the reference to Mafia is funny.  Remember in The Godfather when they told people they were about to kill that it wasn't personal?  Just business.

I saw a cartoon in which St. Peter told an HMO president he was admitted to Heaven, but could only stay three days.  LMAO

Thanks to Crushed et al. for tips on conducting business.

Paris20

Thank you, Crushed, for the legal information and the link to the law school of my alma mater. My husband had a stroke and although he has been admitted to the hospital’s highly-rated intensive rehab Dept. I anticipate possible insurance problems afterwards, depending on my husband’s condition.

John1965

Thank you all. 

I had my financial planner who sold me the policy call to express my frustration. He got the “chapter and verse” of the policy contract, yadda yadda yadda. 

I just finished a 25 page questionnaire in preparation for Monday’s Zoom call assessment by a nurse practitioner. 

There’s simply no time or space to argue with the insanity. I dread the torture that DW will needlessly endure on Monday so the insurance company’s due diligence (attempts to deny coverage) can be met. 

The only silver lining is that DW will forget the encounter.