Issues with Getting LTC Insurance to Pay?

MJulep

My mom has an AMAZING long-term care policy through TransAmerica. But we first filed a claim last September to have them cover her in-home care (we have caregivers with her from 7am-10pm every day and then monitor her movements with a Ring camera that alerts my sister and I if she gets up in the night) and they still have not approved it. They denied it initially, so then we had to file an appeal in January, and we are still waiting for them to let us know.

Has anyone run into this issue before? What are our options? They are very hard to communicate with and all paperwork can only be sent either snail mail or via fax. Should we hire a lawyer? Is there a ombudsperson for this kind of thing?

Thank you for any advice you all might have!

SusanB-dil

Hi MJulep - 

Might have to read the fine print.  In some cases, yes, a lawyer might help. 

In our case, the fine print says she has to 'not be able to do 3 ADL's' (activities of daily living).  Due to covid, they did a half-baked assessment over the phone.  Can she do this... Can she do that... Well, kind'a, but not any of 'this' nor 'that' very well, duh!  Then they wanted to speak to her only. ok, so 'what day is it?' She picked up the stupid calendar and had it 2 days off.  'What month is it?'  Well, she's looking at it!  And we told them that!  didn't matter.  she 'got it right' for the phone assessment. They should have asked her the president (she thinks it is still Clinton or Reagan, sometimes she gets confused which one it is).

mommyandme (m&m)

My moms LTC coverage needed mom to be at a certain level of dementia and the doctor had to diagnose that level first, and we had to privately pay a bit, before they’d activate it.  Also they have clear guidelines on who they’ll pay out to.  I even got my CNA license and don’t technically live with her but they won’t pay me.  They will pay other licensed private CNAs, of course, or Licensed people, nurses, HHAs etc… They also pay for caregivers through home care companies that they approve.  You must read the fine print of the policy to know what they will cover.  I thought I had read it and understood it but there was more finer print info I missed. Although at times it’s frustrating, the LTC insurance has been invaluable and so grateful mom had the wherewithal to invest in it.  

Good luck! 

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MJulep

Thank you for suggestions on what to google! I wasn't sure if we needed an elder care lawyer or some other kind.

CanyonGal

1. Read the policy. Mom had to have 3 ADLs (Activities of Daily Living) or severe cognitive decline. (We had it initially with assistance with bathing, incontinence issues, she needed a walker, and was a fall risk.) She had cognitive decline but not severe (unfortunately we are there now).

I filed the initial claim in 2020. Her facility filled out paperwork and her doctor. I had to visit the respective places in person to get the paperwork filed/faxed and then called the next day to check that they received it because they didn't know what it was for, so it was filed. Now, assessments are with Zoom.

2. It took about 6 months to get the first approval. The first 3 months are out of pocket on this particular policy (in case mom got magically well) and then they reimbursed my facility charges. Every year we have to certify, and mom now needs help with all activities (bathing, dressing, transfer, walking, and toileting.) She can feed herself. She can somewhat dress herself but not appropriately or is half dressed. 

The last certification was done with Zoom and she answered the questions as best she could, and we had to demonstrate the ADL with me standing by her and helping with transfer. (The cognitive decline was severe enough he asked me to step outside into the hallway to ask about delusions.) She qualified in many ways, but I was like "you can't accept the facility or doctor's word? You have to "see" it? " And we had to show the room she was in, and he wanted to see her drugs so I went and showed him the med cart, but I do not have keys to open it, but I can get the nurse to verify? The facility nurse read her prescriptions. It took about 2 hours to get through it all. I think I got an email before the end of the week that we qualified this year.

If you caregiver is with an agency it may be easier to file but the first step is to qualify. 

I found out this year that there is a clause about how many days they will do a "bed hold" and reimburse me for days she was in rehab or hospitalized. We went over 60 days, so we had to pay out of pocket several weeks she was hospitalized. So, I am really glad I have been "saving" extra each month because I knew either Memory Care or a Nursing Home was eventually going to be her fate and they are expensive.

I am really grateful she had the LTC policy especially since we have moved from Assisted Living to Memory Care. Hopefully, the policy will last the remaining years of her life. (She's 87)

My advice is to talk with the insurance team who is on the care side. I had to send DPOA and health care surrogate forms to them. The funds (once approved) are deposited into HER bank account or a check would be sent to her. Ask what documentation they need and if an assessment is going to be at home, who is qualified to give it.

Sleepless in Sleep

As others have said. The fine print will let you know when it starts.

My understanding is that for the vast majority of these policies, my parent’s policy too,  the person would effectively need round the clock care before they will qualify (ie not live at home by themselves overnight).

Dandy1

My LTC policy requires DW to be unable to perform, without substantial assistance from another individual, at least (2) ADL's

or

Requires substantial supervision to protect oneself from threats to health and safety due to Severe Cognitive Impairment.

DW has no problems (yet) with ADL's but could not survive without substantial supervision. DW is still at home and I'm her 36 hour a day caregiver. I suspect the day will arrive when we will use the LTC benefits.