Mother's Long Term Care Insurance Company Giving Me the Run Around

[harllee]

DM, age 90, has dementia, congestive heart failure, and has had several falls. She is in a CCRC, has been in independent living, recently moved to assisted living but doctor says she needs more help, will probably need to go to skilled nursing or memory care. DM is having difficulty with activities of daily living (needs help showering, going to bathroom, etc). I am her POA, my sister is her HCPOA. She has a long term care insurance policy that she has had many years (and has paid more in premiums that she can ever get in benefits). The policy is with MetLife (was with Prudential but MetLife took the policy over many years ago). I have begun the claims process with the assistance of the CCRC but we are getting the run around. First they claimed they could not find a policy on DM. I had to FAX (who faxes anymore), copy of policy, proof of premium payment (they debit it every month!) They needed copies of my POA by FAX, claim they never received, having to send again. Then they need many doctors records, they claim they never received, doctor has to send again at my cost.

I think they are delaying because they do not want to pay and hoping I will give up, nope that is not going to happen. I have spent many hours on this over the last couple of months.
Anyone here had any experience dealing with MetLife LTCI claims? Does anyone know of any attorneys or advocates that specialize in LTCI claims? I have gotten a couple of attorney's names from mother's CCRC so I will pursue those but it will be expensive.

Mother's CCRC says this is typical of all LTCI companies, the do anything they can to avoid paying claims.

 

[Sunset]

I think paying a lawyer will largely eat up a lot of the benefit..
Before doing that , find out what gov't dept is responsible for making the insurance company follow the rules.
Call the gov't office, explain the issue, send them a letter. Then start CC'ing the gov't dept on each letter/fax you send to the insurance company. (put CC on everything sent, even if you don't actually cc each thing).

I've been told by a previous ins claims clerk, they get rewarded for denying/delaying payouts, she found it morally objectionable and quit.

 

[neihn]

I've been told by a previous ins claims clerk, they get rewarded for denying/delaying payouts, she found it morally objectionable and quit.

Wow! I am speechless!!!

 

[athena53]

Before doing that , find out what gov't dept is responsible for making the insurance company follow the rules.
Call the gov't office, explain the issue, send them a letter. Then start CC'ing the gov't dept on each letter/fax you send to the insurance company. (put CC on everything sent, even if you don't actually cc each thing).

This. Here's the directory of state regulators in the US.

https://content.naic.org/state-insurance-departments

It's their job, among other things, to make sure that insurers pay their claims as promised, Insurers do NOT like being reported for bad-faith claims handling, which is what this is. If the regulator gets too many complains they may actually come in and audit the company. They're walking a fine line, of course- I'm sure they don't want to see the company become insolvent, either, but it's worth a try. The few times I've had an insurer give me the runaround on a legitimate claim, a tactful threat to involve the Insurance Commissioner has made them snap to attention.

 

[harllee]

Good idea about contacting NC Department of Insurance.

 

[MarieIG]

I noticed on the State website a portal for filing a complaint (it was on the Medicare page, but indicated long term insurance.

https://www.ncdoi.gov/consumers/medicare-and-seniors-health-insurance-information-program-shiip

I would read through the entire policy and see what is necessary to trigger the insurance. (It has probably already been met.) I would then prepare for your easy reference a memorandum outlining your communications to have that handy, and also keep proof of their receipt of all prior communications. I would send a letter to the carrier CMRRR outlining your communications, their failure to properly maintain documentation, advise that you are claiming expenses back dating from your first notification, and that if you do not receive benefits within X days, you will be contacting the State, reporting their dilatory tactics, and seeking all remedies available to you DM under the law.

I suspect they are fully aware of their obligations, but "the squeaky wheel" . . .

 

[REWahoo]

After hearing a few horror stories about issues with LTCI claims I brought the subject up with our elder law attorney. She said there were professional resources to assist with LTCI claim difficulties short of getting an attorney involved and gave me the name of someone local.

Based on her recommendation I'd contact one of these individuals/companies to see what services they offer and the associated cost. A quick Google search of "long term insurance claims assistance" brought up several hits, these three looked promising.

Note that I have no first-hand experience with the examples I link below, my knowledge of them is only what I read on their websites.

https://familysolutionsforcare.com/services/
https://mrsltc.com/
https://villageplan.com/home-care/long-term-care-insurance-advocacy/

Sincerely hope you find some help in dealing with these issues! Please let us know what you end up doing.

 

[FloridaJim57]

See if you can enlist the help of a local "Action Reporter". companies hate bad publicity and usually cave real fast once a light is shined on them.

 

[Z3Dreamer]

DW and I have Prudential LTC so I am very interested in this. I have a few questions: 1) Is there a claims adjuster or case worker (or some other similar name) assigned to your case? 2) Once a new piece of paperwork is sent, how long does it take for the insurance company to deny based on some new missing item? 3) Is the denial emailed or onlined to you or is it up to, after waiting some time, to try and find out where things are?

Thanks and sorry you are going through this.

 

[badatmath]

The only other person I know who tried to use LTC on his sick wife gave up after tons of paperwork and repeated denials. I think it is absolutely a thing they do to delay.

 

[harllee]

DW and I have Prudential LTC so I am very interested in this. I have a few questions: 1) Is there a claims adjuster or case worker (or some other similar name) assigned to your case? 2) Once a new piece of paperwork is sent, how long does it take for the insurance company to deny based on some new missing item? 3) Is the denial emailed or onlined to you or is it up to, after waiting some time, to try and find out where things are?

Thanks and sorry you are going through this.

I have not even got this far since they are claiming DM does not even have a policy with MetLife even though I have sent them a copy of the policy and they have been debiting her account every month AND we just got a letter from them a few month ago increasing her premium by 25%! I think they are hoping that it they delay things enough my sweet mother will die before they have to pay a penny.

 

[harllee]

The only other person I know who tried to use LTC on his sick wife gave up after tons of paperwork and repeated denials. I think it is absolutely a thing they do to delay.

Yes I think that is what they are doing, hoping mother will die before they have to pay anything.

 

[Momcpa]

But if your Mother passes away while you are fighting against these denials......wouldn't they still have to pay the covered expenses up to that point It wouldn't seem like her passing would absolve the insurance company from rightfully covered expenses that are submitted on her behalf while she was alive. Am I wrong here? It would be good to know.
Years ago, my Dad fought Social Security on my Mother's behalf for disability. Eventually, they paid retroactively. I guess I thought LTC might work the same way.

 

[harllee]

But if your Mother passes away while you are fighting against these denials......wouldn't they still have to pay the covered expenses up to that point It wouldn't seem like her passing would absolve the insurance company from rightfully covered expenses that are submitted on her behalf while she was alive. Am I wrong here? It would be good to know.
Years ago, my Dad fought Social Security on my Mother's behalf for disability. Eventually, they paid retroactively. I guess I thought LTC might work the same way.

True but there is a 90 day waiting period. And I think the insurance company figure the family will just give up after the insured dies.

 

[badatmath]

Yes I think that is what they are doing, hoping mother will die before they have to pay anything.

Sad they can get by with that sometimes. Hope you can get it taken care of.

 

[harllee]

Sad they can get by with that sometimes. Hope you can get it taken care of.

I am going to try my best, I already have spent many hours on this, hours which I should be spending my with my mother.

 

[Act2]

My Dad’s LTC was with another company, but story sounds similar.

 

[Koolau]

Anyone here had any experience dealing with MetLife LTCI claims? Does anyone know of any attorneys or advocates that specialize in LTCI claims? I have gotten a couple of attorney's names from mother's CCRC so I will pursue those but it will be expensive.

Mother's CCRC says this is typical of all LTCI companies, the do anything they can to avoid paying claims.

Not MetLIfe (infact, don't recall the LTCi name) but my mom had very little problem with her LTC insurance company. I had one person I called (direct line) if there were any issues. This nice lady even advised me that we could requalify my mom for coverage by having her at home for 6 months and paying premiums. That would restart the clock on her benefits. BUT that was simply impossible for mom. In short - It was a relatively good experience, considering the issues surrounding long term care.

 

[zl55lz]

I had excellent success contacting the local Congressman about an issue getting help expediting something for my spouse's elderly dad, and although not related to longterm care, it might be worth a try. Do not underestimate the power of a Congressperson. My opinion is no company wants to be on that radar.

 

[MichaelB]

I had excellent success contacting the local Congressman about an issue getting help expediting something for my spouse's elderly dad, and although not related to longterm care, it might be worth a try. Do not underestimate the power of a Congressperson. My opinion is no company wants to be on that radar.

This is a good idea. Complaining to the state insurance regulator may also help. Insurance is state regulated and the regulators have a great deal of influence.

Nords wrote a thread detailing all the issues he dealt with trying to get LTCI to pay for his fathers care. It was written more than 10 years ago but this situation looks quite similar. https://www.early-retirement.org/fo...-and-asset-allocations-55688.html#post1064097

 

[harllee]

This is a good idea. Complaining to the state insurance regulator may also help. Insurance is state regulated and the regulators have a great deal of influence.

Nords wrote a thread detailing all the issues he dealt with trying to get LTCI to pay for his fathers care. It was written more than 10 years ago but this situation looks quite similar. https://www.early-retirement.org/fo...-and-asset-allocations-55688.html#post1064097

Thanks for the Nords thread, I had forgotten about it. When I get a chance I will read all through it.

 

[Koolau]

Yes I think that is what they are doing, hoping mother will die before they have to pay anything.

I suppose that's probably true, but if the facts eventually validate the claim, it must still be paid by the insurance company - even after the death of the client. Most likely, they are attempting to wear the clients down. Inexcusable. Call the state insurance regulators. Most of them have teeth and occasionally use them.

 

[athena53]

I suppose that's probably true, but if the facts eventually validate the claim, it must still be paid by the insurance company - even after the death of the client.

If the insurer decides to contend that she didn't need that level of care, though, it may be difficult to prove that after her death- it might even make sense to get her evaluated now even though the OP is fighting a battle right now even to get them to admit that she has a policy with them.

 

[Koolau]

If the insurer decides to contend that she didn't need that level of care, though, it may be difficult to prove that after her death- it might even make sense to get her evaluated now even though the OP is fighting a battle right now even to get them to admit that she has a policy with them.

IIRC the ball is in the insurance co.'s court. I assume the proper forms have been filled out by her doctor(s) "certifying" that she meets the requirements. It would then be up to the ins. co. to prove otherwise which would be difficult once the client is deceased.

I have just told you more than I know so YMMV.

 

[harllee]

IIRC the ball is in the insurance co.'s court. I assume the proper forms have been filled out by her doctor(s) "certifying" that she meets the requirements. It would then be up to the ins. co. to prove otherwise which would be difficult once the client is deceased.

I have just told you more than I know so YMMV.

I have had mom's doctor fill out the forms and fax them to the insurance company and the insurance company now says they never received them. Anyway they cannot find DM's policy even though I also faxed them a copy. Total incompetence. Next stop--state insurance commissioner.