REWahoo
Give me a museum and I'll fill it. (Picasso) Give
As the owner of a LTC policy I've had an ongoing concern about the ability to actually receive benefits should the need arise. There have been many anecdotal [-]horror stories[/-] reports of major difficulty in collecting on these policies, but nothing authoritative on the industry as a whole. Then I found this:
NATIONAL LONG-TERM CARE INSURANCE CLAIMS DECISION STUDY conducted by the U.S. Department of Health and Human Services in 2010.
The purpose of the study:
Methodology and LTCi carriers in the study:
A key finding:
The (surprising to me) Conclusion:
My read on this is "the devil is in the details" when it comes to the documentation required to successfully file a claim. That's why enlisting the services of a company specializing in filing LTC insurance claims may be well worth the money, especially to file the initial claims to get benefits started.
NATIONAL LONG-TERM CARE INSURANCE CLAIMS DECISION STUDY conducted by the U.S. Department of Health and Human Services in 2010.
The purpose of the study:
...to conduct a thorough scientific review of an industry-wide sample of private LTCI claims decision made in 2007 and 2008 in order to determine and quantify the extent to which those decisions were appropriate. More specifically, we focused on answering two broad questions:
1. Is the denial of benefits to policyholders making claims on their policy
appropriate? and;
2. Is the approval of benefits to policyholders making claims on their policy
appropriate?
Methodology and LTCi carriers in the study:
We reviewed a sample of claims from seven of the largest LTCI carriers in the United States in order to determine if the decisions made for those claims are appropriate. The following carriers provided a sample of their claims decisions:
− Bankers Life and Casualty
− Genworth Financial
− John Hancock
− Long Term Care Partners
− Medamerica
− Metropolitan Life
− Prudential
These companies represent major carriers that are currently selling policies in the individual and group markets, with significant claims numbers for analysis. Together these companies comprise more than 70% of the in-force claims
A key finding:
Regarding denial decisions, we found that in all cases, there was no evidence to suggest that the individual met the tax-qualified criteria for benefit eligibility in their policy. This would suggest that companies are consistently applying their clinical contract language to their claims decisions.
The (surprising to me) Conclusion:
The detailed review of more than 1200 claims decisions suggests that when a third party independent audit is conducted, clinical benefit eligibility decisions are in line with the supporting documentation in the files and the contract provisions of the policy. The data suggests that when disagreements were present between the audit team and the insurance company adjudicators, they were more likely to be about approval decisions rather than denial decisions. Put another way, insurance companies tend to err slightly on the side of approving claims that may not meet policy contract benefit eligibility.
My read on this is "the devil is in the details" when it comes to the documentation required to successfully file a claim. That's why enlisting the services of a company specializing in filing LTC insurance claims may be well worth the money, especially to file the initial claims to get benefits started.
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