Articles Posted in Long Term Care Insurance Claims

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health-ins-policy
When a parent reaches the point of needing long term medical or assistive care, sometimes a family member cannot locate the actual policy even if they know a long term care insurance policy exists.  How do you get a copy of the policy?  One tactic used by insurance companies is to delay everything – including the simple task of complying with a request for a copy of the policy itself.  They also know that if the policy’s language (terms and conditions of coverage) is not consulted early on, damaging statements regarding the condition of the insured and the type of care needed are often made to the detriment of obtaining coverage for the insured.

Knowledge of and citation to the Florida statutes should help to get a copy of the long term care policy asap.

Florida law requires insurance companies to promptly communicate with policyholders:  “acknowledge and act promptly upon communications with respect to claims.”  Fla. Stat. § 626.9541(1)(i)3.c.  In addition, another Florida statute requires the insurance company to represent policy provisions accurately and relate claim decisions to applicable policy language.  See Fla. Stat. § 626.9541(1)(i)3.b and Fla. Stat. § 626.9541(1)(i)3.f, respectively.

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are-you-covered
Let’s face it, many people stuck in the middle taking care of both elderly parents and their own children, are overwhelmed when the Long Term Care Insurance company denies coverage for their loved ones.  Who has the time to deal with this with our otherwise busy lives?  Who has the knowledge to go toe to toe with the insurance company and force them to grant coverage?  And does it really make a difference with Medicare picking up the pieces if coverage is denied?

American Society on Aging addresses some common misnomers about what Medicare covers when long term care is needed.  The ASA pointed out that contrary to recent surveys which show that the public believes that Medicare pays for long-term care, this is not what happens in reality.  Medicare tries to limit its availability for the provision of personal and assistive care services.  If skilled nursing or rehabilitative services are needed, that’s where Medicare kicks in.

Medicare.gov defines long-term care as a range of services and support for personal care needs.  Most long-term care isn’t medical care, but rather help with basic personal tasks called activities of daily living (bathing, eating, dressing etc.)  The site states very clearly:  “Medicare doesn’t cover long-term care (also called custodial care), if that’s the only care you need.  Most nursing home care is custodial care.”

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insurance-claim-denied
Can a doctor at an insurance company make a decision to deny care if he or she doesn’t even look at the patient’s medical records?

This is a question that the California insurance commissioner Dave Jones will be looking at during a new investigation of Aetna following this stunning admission.  Jones told CNN his expectation would be “that physicians would be reviewing treatment authorization requests.”  I think we all would agree.

This is concerning to us as consumer attorneys in Florida who note that Aetna is a long term care insurance company who reviews people’s applications for nursing home and Assisted Living care.

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