“This is why we do what we do! Our client was taken off claim 11/16/17 due to no/lack of documentation on her ADLs (Activities of Daily Living) from the facility. We filed an appeal on 1/5/2018 and today they approved her back to 11/17/17! Hooray!” Jeanne Garoutte, Consumer Claims Specialist.
Care providers are almost always caring humans who love taking care of people. With 400,000 variations of long-term care policies and riders, there is no way for them to know the intricacies of each policy.
Even if documentation is submitted correctly, long-term care insurance claims is a very human business because there is no uniform way to handle them. Faxing, emailing, or uploading documentation, does not guarantee full arrival at the carrier.
In addition, missing supporting medical records substantiating the claim can cause claim payments to stall. Paid and sometimes, unpaid, caregiving received prior to filing a claim may be reimbursable.
Caregiving facilities have seen misguided advice to a family regarding their policy benefits, backfire. Ultimately, if the policy does not pay, it is up to the resident and/or their family to pay the bill in full.