In May of this year, I started working with a client and her daughter.The client had been on claim with her Long-Term Care Insurance policy (LTCi) since the first of this year. At the end of April, she went through re-certification with her insurance company, and due to incorrect documentation on her assessment and plan of care from her assisted living facility, she failed to remain claim eligible and thus fell off claim.
In tears and scared, she reached out to us, FSC and became my client. After requesting and reviewing all documentation leading up to this denial, I worked with the Assisted Living Facility’s Executive Director and care team to determine the actual care my client required and was receiving.
I learned, as I see on many of my client’s cases, that she was receiving the right amount and type of care to continue to meet claim eligibility – it just wasn’t documented correctly in the facility’s care assessment and plan of care.
This is the primary reason we see LTCi claims denied or stalled.
Once we determined she was most likely eligible for claim, I worked closely with the Executive Director and care team on an accurate plan of care. I also requested updated medical records from her primary physician to make sure the medical records agree with the plan of care for her.
This is time consuming and tedious process, but the only way the insurance company will reconsider a claim is with 100% accurateness.
Even though it is frustrating – I did not submit anything to the insurance company until we had every supporting piece of documentation in place. (One thing we have learned along the way is that some insurance companies add 30 days to their review process every time they receive a new piece of documentation.)
When all the records were in order I wrote an appeal letter and submitted a thorough package to the insurance company. On Friday, I was able to call the family and let them know the decision and been overturned retroactive to May. The family is relieved and extremely grateful.