When the Long-Term Care Insurer Refuses to Pay

My dad was a smart guy, but not so smart as to avoid being hoodwinked by those who drafted the contract for my mom’s long-term care insurance policy.

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When my father died in 2013, he went to his grave imagining that my mother, then an Alzheimer’s patient, would get the policy’s promised home care that he would no longer be able to deliver. He’d paid its premiums for about 20 years.

After my dad’s passing, I chanced upon a caregiver, a lovely European woman from the country of my mom’s birth. She had been certified as a social worker and nurse after 1,200 hours of training in her home country. The certificate attested to her ability to “perform basic nursing and caretaking activities, assess peculiar needs of geriatric care, perform caretaking duties of the elderly and perform administrative activities related to geriatric care.”

She moved into my mom’s home and cheerfully began to minister to my mother’s every need. A perfect fit — I thought.

I put in a claim with mom’s long-term-care insurer (a major player in the business), expecting approval reimbursing us in short order for the caretaker’s work.

Much to my shock, the claim was rejected.

Here was the sticking point and the insurer’s grounds for denial: According to the policy, the caretaker I’d hired did “not provide services to (my mother) as an employee of an entity that has an agreement as a provider of home health care services or hospice services under the Medicare program or that is licensed or accredited by state law as a Home Health Care Agency or hospice.”

And, the insurer said, “she is not a licensed therapist, a registered nurse, licensed practical or vocational nurse operating within the scope of such a license.”

I promptly appealed.

This was my argument: The insurer’s letter of denial enclosed a list of home health care agencies it recommended for a so-called properly qualified home health aide. But after I called a number of them, I learned that home health aides receive about 75 hours of training, far less than the 1,200 hours my mom’s rejected caregiver had received.

Moreover, I learned that home health aides are forbidden to administer medication. That in itself was a major problem. Without someone like the European aide to give my mother her meds, Mom would have been forced to leave her home and go to a long-term care facility, the very thing my parents had sought to avoid by buying the policy in the first place.

I felt that I was able to bolster my argument when I read that the insurer itself was in the business of training home health aides. According to its online training site: ‘Many home health aides use the training as a stepping stone to see if the health field is something they enjoy. If so, they often continue their education to become nurses’ aides…’

This, as I saw it, implicitly acknowledged that a nurse’s aide has more training than a home health aide, providing further confirmation that my mom’s caretaker was more qualified to help my mother than the home health care aides trained by the insurer.

What’s more, any of the insurer’s approved care providers would have cost my mom considerably more than her current caregiver.

My appeal fell on deaf ears.

Worse, there was an infuriating pattern of delay hearing back. The insurer’s preferred mode of communication was snail mail. And, I noticed, its letters arrived weeks after they’d been postmarked. The insurer also repeatedly requested I re-submit documents.

I was invited to re-appeal, if I had new evidence to submit. Since I didn’t, I called the insurer and asked the company to “do the right thing” by my mom. Pointedly, I mentioned that I was aware that it had  many complaints on social media as well as in the courts. I indicated that I was committed to adding my voice and efforts to the complaints.

Not incidentally, I mentioned that my mom had just qualified for home hospice care, implying that she would not be long for this world and therefore a relatively short-term burden to the insurer.

After months of dogged efforts, I finally prevailed. The insurer wrote me that the company would make a one-time exception in my mother’s case, subject to re-evaluation at some point later on.

In the end, my mom defied all expectations and lived for several years more. The insurer paid out almost the maximum promised by the policy. So, thankfully, my mother was able to live out her final years in the comfort of her home.

Unfortunately, my family’s troubling experience with long-term care insurers doesn’t end there.

My mother’s twin sister was also afflicted with Alzheimer’s in the last years of her life and held a similar policy to the one my mom had. But my aunt didn’t have an advocate like me. Her claim was summarily rejected by the insurer.

My aunt died shortly thereafter, unable to afford the home care the insurer had finally made available to my mom after my protracted efforts.

What is the lesson I learned from the experience of my mom and her sister?

Before signing a long-term care policy, know the implications of every sentence in it. Get some professional advice, too. And never stop advocating for yourself or your loved ones to get the care — and reimbursement — you believe is due.