The condition of a retiree suffering from dementia and Parkinson’s Disease progressed so severely that he became wholly dependent on his wife to assist and supervise his daily activities. The senior had a long-term care insurance policy, which would pay hundreds of thousands of dollars in annual home care benefits if he qualified under the policy. The couple filed a claim for benefits when his need for care and supervision on a 24/7 basis exceeded what his wife could provide, despite her best efforts.
The Challenge
The insurance company denied the policyholder’s claim on the basis that he did not meet the eligibility criteria under his long-term care policy. Under the terms of the policy, one of the ways to establish eligibility for long-term care benefits is to submit evidence of a severe cognitive impairment that requires substantial supervision to protect the policyholder from threats to his health and safety. Given the insured’s indisputable diagnoses of dementia and Parkinson’s Disease, the couple thought there would be no problem establishing his severe cognitive impairment. They provided his medical records, completed a daily activities questionnaire, and even submitted to a health care practitioner’s assessment. In the end, though, the insurance company denied the claim.
Completely perplexed by this result, the couple persisted and personally submitted two appeals to the insurance company. Included within these appeals were a host of additional medical records from several of his treating physicians. The couple wanted to show that multiple doctors were in agreement that he suffered from a severe cognitive impairment. The appeals were written by his wife, who as his sole caregiver had more firsthand knowledge of her husband’s condition than anyone. A significant portion of the appeals focused on the types of tasks she performed for him, the dangers she witnessed, and the toll his conditions had taken on both of them. Sadly, the insurance company continued to reject the claim.
The Solution
Unwilling to settle for this unjust result, the couple turned to Schwartz, Conroy & Hack PC. From our review of the documents submitted in support of his claim, both initially and on appeal, it was immediately apparent to us that the insured suffered from a severe cognitive impairment as required under the policy for entitlement to benefits. Significant evidence within his medical records existed to prove this, but it needed to be emphasized appropriately.
The unfortunate reality is that the more pages of records you throw at an insurance carrier, the less likely it is that the majority will actually be read. For this reason, our Firm recognizes the importance of putting your best foot forward. We analyzed every single page of the medical records that had been submitted to select only those we confidently knew would support the claim. In our analysis, we discovered multiple reports of specific tests demonstrating the policyholder’s neurocognitive decline. We took these reports and made them the complete focus of our own submission to the insurance carrier.
Through direct reference and emphasis on only these select reports, we objectively proved to the carrier that the gentleman did, in fact, meet the criteria for which benefits were due. In addition, we contacted counsel for the insurance company and advised counsel that continued rejection of this client’s claim was not only horrific and unjust, but would expose this company to bad faith damages beyond those the insurance should be paying already. Counsel knew our firm from prior lawsuits and by reputation. Faced with bad faith exposure and with a spotlight on this powerful medical evidence, the insured reversed its prior denials and approved the insured for long-term care benefits, paying our client in full, retroactive to the start of his claim.
The Result
The letters previously denying our client’s claim had contained this language: “The information reviewed consisted of the following records from [Dr. X], [Dr. Y] and [Dr. Z]. Based on the information reviewed, we have determined that you do not meet the benefit eligibility criteria of your coverage.” In the eventual approval of benefits we obtained for our client, the insurance carrier’s letter used this familiar language: “Based on the information we received from [Dr. X], [Dr. Y] and [Dr. Z], we have determined that you currently meet the benefit eligibility criteria of your policy.”
Weren’t these the same doctors originally referenced? Yes. Consisting of the exact same records provided previously? Yes. Without anything new submitted for their review? Yes. How, then, can the same set of information produce completely opposite results? Simple, if you know what to look for and how to best present it.
The select medical reports that our Firm highlighted were not new material. They were part of the medical records attached to the prior appeals. We put them at the forefront, made them the focus, and also communicated with an in-house lawyer whose job it is to protect the insurance company from unnecessary risk. By knowing not only which information holds the most value, but also knowing what will get the insurance company’s attention, we were able to get our client his benefits – benefits worth millions of dollars.
