It appears that many companies that sold long term care and home health care insurance had little idea of what a claim would involve or that at some point they would be responsible for the payment of so many claims. Over the last several years, many companies have attempted to avoid the payment of benefits by either misinterpreting, narrowly interpreting, or simply ignoring policy terms and/or benefit options.
Most long term care and home health care policies promise the payment of daily insurance benefits to either a home health care provider or nursing home type facility if the insured can demonstrate the following:
•1. We are given proof, satisfactory to Us, that you are Chronically Ill; and
•2. A Licensed Health Care Practitioner has certified in writing to Us, in the last twelve (12) months, that you are Chronically Ill; and
•3. A Plan of Care including a Qualified Long-Term Care Services You need is in place for you.
“Chronically Ill” means the patient is unable to perform, without “Substantial Assistance” from another individual, at least two (2) “Activities of Daily Living” (“ADL”) due to the loss of physical or cognitive functional capacity.
“Substantial Assistance” usually refers to both “Hands-On Assistance:” The patient requires the physical assistance of another person without which the patient would be unable to perform the ADL or “Stand-By Assistance:” The patient requires the presence of another person within arm’s reach of him that is necessary to prevent, by physical intervention, injury to him while he is performing the ADL.
“Activities of Daily Living” tend to include::
Bathing: Washing oneself by sponge bath; or in either a tub or shower, including the task of getting into or out of the tub or shower.
Dressing: Putting on and taking off all items of clothing and any required braces, fasteners, or artificial limbs.
Transferring: Moving into or out of bed, chair or wheelchair.
Toileting: Getting to and from the toilet, getting out and off the toilet, and performing related personal hygiene.
Continence: Ability to maintain control of bowel and bladder function; or, when not able to maintain control of bowel or bladder function, the ability to perform related hygiene (including caring for catheter or colostomy bag).
Eating: Feeding oneself by getting food into the body from a receptacle (such as a plate, cup or table) or by feeding tube or intravenously.
Long Term Care and Home Health Care policies do not require that the insured be a complete invalid; only that they cannot safely or competently perform two or more of the ADLs listed above without either hands-on or stand-by assistance. Not surprisingly, carriers, in an effort to avoid payment, allege that the insured’s ability to be mobile and renders them ineligible for benefits. In fact, many insurance companies now conduct surveillance on their insureds to “catch” them grocery shopping or running an errand in an effort to misrepresent the facts and create false evidence that the insured is not eligible for benefits. The truth, however, is that the ability to grocery shop or run an errand does not mean that the individual can safely or without assistance bathe, dress, or toilet. Even worse, is that many of these insureds are elderly and do not have the resources or energy to fight the insurance company. At DI Law Group, we aggressively advocate for our client and take the steps necessary to obtain the benefits they were promise and for which they paid under their Home Health Care and Long Term Care policies.
Another commonly disputed issue is the length of time benefits are payable during an insured’s lifetime. Many policies provide for a Restoration of Benefits if there is an 18 month period between the date the insured last needed assistance with at least two of their Activities of Daily Living and the date they next require such assistance. An example of such a policy term is the following:
Maximum Benefit Period: The Maximum Benefit Period is the maximum benefit we will pay during your lifetime, UNLESS benefits are restored as provided for in the Restoration of Benefits provision.
Restoration of Benefits:
If You have received Benefits under the policy and have used up a portion of your Maximum Benefit Period, BUT have recovered sufficiently to no longer require Home Health Care (HHC) or Long Term Care (LTC), we will RESTORE your HHC and LTC to its FULL ORIGNINAL MAXIMUM each time you meet the following qualifications:
1) You must not have received HHC or LTC, Adult Day Care or Hospice Service for a period of 180 consecutive days; AND
2) Your Physician must certify that you have sufficiently recovered to no longer require any of the foregoing services and that you have sufficiently recovered to no longer require any of the foregoing services and that you were not advised to obtain Home Health Care, Long Term Care, Adult Day Care or Hospice Care..
There is no limit to the number of times your Maximum Benefit Period may be restored.
When the Insured first advises their carrier that benefits are no longer necessary as they no longer need assistance, the carrier stops payment without issue. However, in those cases where the Insured requires Home Health Care or Long Term Care assistance 18 to 24 months later, many carriers become suspicious and allege that their insured actually needed assistance earlier than that, but chose to wait at least 18 months so that their full benefit period would be restored. This, of course, is the only time the insurance company claims it should have been paying benefits, even though none were requested. Moreover, many carriers fail to conduct a proper investigation or contact the insured’s physician to confirm this misallegation. Instead, they use their own in-house physician to simply review the medical records and make a determination based on what they’ve read. At DI Law Group, we make sure our clients medical records clearly are properly documented and that the insurance company has the information it needs to make an accurate decision regarding our client’s right to home health care or long term care insurance benefits.
If you have any questions about your Home Health Care or Long Term Care Policy, please contact us for a free consultation. Our firm has handled numerous Long Term Care and Home Health Care disputes on issues ranging from policy language disputes to biased surveillance and prejudicial medical reviews.