Client to Long Term Care: Five Months Is Too Long To Approve Claim

My client’s son called me up today to lament about dealing with a long term care insurance company (LTC) for his mother.  He had filed the claim back in September and it is now February.  Since the initial claim, my client has been hospitalized three times, fallen and been to rehab.  The doctors at the hospital would only send her home with 24 hour care.  The money was needed.

I explained to my client’s son  this is standard operating procedure for LTC companies. The process is complex and cumbersome.  They stall, asking for this or that, with no rhyme or reason.   First, there is an initial phone interview with the person filing the claim.  Then, if the customer service person thinks it is an acceptable potential claim, then an application is sent.  After the application is completed, then the client’s doctors are sent information to be filled out.  As papers arrive, they are reviewed by a medical team who often request more documents or question medical treatments and diagnoses.  Time and more time elapses.

I tell people it is imperative to constantly call to find out where you are in the process.  The reason to be vigilant is, if you don’t call papers can sit on someone’s desk for a very long time.

So my client’s son called  regularly and after the last hospitalization and rehab began in earnest.  He had many promises and apologies but approval or reimbursements for out of pocket payments for 24 hour care were not forthcoming.  Last Monday, he called once again and got the same story except this time he said the following:

“If I don’t receive a call from you by Friday at nine approving my mother’s claim, the next call you get will be from my lawyer, who will be telling you, he is filing an official complaint with the Department of Insurance and the Attorney General’s Office.”

8:45 AM Friday morning, he received the call from the LTC case manager stating the claim had been approved.  Imagine that.

Why does LTC  companies play this game?  My personal feeling is if they can wait it out either the person will stop trying or will die.  Either way, they win.  It is very frustrating because most people have been paying monthly premiums for decades and nothing prepares you for the fight to get reimbursement.    What a crazy system!