Once you have submitted your long term care insurance claim, your insurance company will almost always contact you to set up an in-home evaluation. A cornerstone of long term care claims, the in-home evaluation can be the difference between having your claim approved or denied. For this reason, it is crucial that you prepare for it.
In a recent eBook entitled “The Essential Long-Term Care Insurance Benefits Handbook,” Schwartz, Conroy & Hack, PC Partners Evan Schwartz and Michail Hack discussed how to prepare for the in-home evaluation and what steps you can take if your claim is ultimately denied.
What To Expect from the In-Home Evaluation
Long term care insurance claim benefits are generally triggered if a policyholder can no longer perform two of six activities of daily living (ADLs), which include eating, bathing, dressing, transferring, toileting and continence, or if the policyholder suffers from a cognitive impairment that renders independent living unsafe.
After you submit your claim for benefits, the insurance company will hire an independent firm, which will send a registered nurse or other healthcare professional to your home to evaluate your claimed ADL disability and/or cognitive impairment.
It is crucial that you not attend the at-home evaluation alone. You should have an informed family member, attorney, healthcare provider or other advocate present to ensure all relevant information is properly disclosed and fully reported to the evaluator. For several reasons, insured individuals tend to under-report their limitations. They may be reluctant to admit them due to pride or they may forget to bring them up due to a cognitive issue or the stress of having a stranger in their home asking them all kinds of intimate questions.
The evaluator (usually a nurse) will ask for basic information such as your driver’s license, date of birth and Social Security number. The evaluator will ask about your medical history, including who your primary care and other physicians are and what your diagnoses are. The evaluator will ask you to take out your medications to check the prescribing physicians and whether you are compliant with taking your medications as prescribed. To help the evaluation go smoothly, have all of the necessary information and items readily available, and be sure to practice asking and answering questions with your advocate prior to the evaluation.
Mental Status Evaluation
The evaluator will perform a basic mental status evaluation, asking questions like what time of year it is and which U.S. state you are in. The evaluator may ask you to repeat three words, such as “look, like, tree” in order and then to recall them and repeat them again later in the interview. The evaluator will also make notes about your level of consciousness and how responsive you are.
This evaluation is so basic that it is not uncommon for someone who suffers from debilitating cognitive impairment to pass it. Unfortunately, insurance companies may point to this test when denying benefits, which is why it is important to have your own strong evidence of any cognitive impairment.
The evaluator will also gauge your ability to perform the ADLs. Prior to the evaluation, it’s critical that you review your policy closely, which details your insurance company’s definition of disability in activities such as dressing and bathing, which can vary from policy to policy. The evaluator’s checklist may not be compatible with your insurance policy’s definitions. For instance, in one claim denial that we helped overturn, the policy’s definition of dressing included the ability to take on and off shoes and socks, and this was something that our client was unable to do. Shoes and socks were not mentioned on the evaluator’s checklist, however, so she never asked the policyholder to demonstrate her ability to put on or take off her shoes and socks, and this was a primary reason for the denial. Go through all of the ADLs with your advocate in advance of the evaluation to make sure you’re aware of what you can and cannot do and that you know how to properly convey this.
What To Do If Your Claim Is Denied
If your claim is denied out initially or terminated later, we typically focus on three particular fixes. Schwartz, Conroy & Hack has almost 300 active claims in the claims process. In most cases, we are able to get the claims paid without having to file a lawsuit. Our strategies for overturning a denial or termination often focus on one or more of the following: getting better medical support or better proof of a cognitive impairment, written statements by the insured/family members, and an additional in-home evaluation.
Depending on the situation, the evidence provided by the doctor may not be complete or compelling enough. We may focus on getting the doctor to write a more persuasive statement or to correct something that was inaccurate in supporting that the patient is unable to perform at least two ADLs or suffers from cognitive impairment.
Statements by Insured/Family Members
In some situations, insured individuals may not have explained themselves well enough or may have underreported their limitations. We often work with clients to provide personal statements that include details about their limitations and how their daily lives are impacted, which may have been left out of the claim form, the in-home evaluation or both. Personal statements from the insured, along with close friends or family members, can help unlock the door to benefits.
Get Your Own In-Home Evaluation
Another option is to get your own in-home evaluation. We work with some clients to bring in a qualified healthcare professional to mimic what the insurance company’s evaluator does. The evaluator may have missed the boat on something, leading to the denial, and having a qualified evaluator point it out is a very effective way of revealing the flaws of the original evaluation.
While other claim problems may need to be fixed, getting these three things squared away is the core and essence of what we look at in overturning a denial or termination of benefits. If all these efforts fail and a lawsuit is needed, we will aggressively pursue litigation to force the insurance company to keep its promises. Download our Essential Long-Term Care Insurance Benefits Handbook for more information.
Schwartz, Conroy & Hack, PC represents businesses and individual insurance policyholders in claims and litigation against insurance companies. We make sure insurance companies keep the promises they made to policyholders like you.
Contact us today for a free consultation.
Evan S. Schwartz
Founder of Schwartz, Conroy & Hack