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Long-Term Care Insurance Headaches? Great help with 1 click.

Long-Term Care Insurance frustrations

Long-Term Care Insurance can be challenging to navigate.

Abby Services helps seniors navigate confusing long-term care insurance policies to be sure they get all of the in-home care benefits they are entitled to.

Abby Services has helped Fort Myers and Cape Coral seniors navigate confusing long-term care insurance policies since 1997!

With many clients we see, their long-term care insurance policies were purchased years ago. Clients may not remember clearly what policy details are or may incorrectly remember information about their long-term care insurance policy.

It’s no wonder clients can be unclear about coverage benefits or requirements to access their policy. Often the language in long-term care insurance policies can be challenging and confusing to understand.

That is why when a client has a question about their long-term care insurance policy, or benefits, they should schedule a complimentary appointment with one of our owners and  RN Scott Strachan.

Although these meetings can take about an hour, it is important to thoroughly review a long-term care policy, and fully explain its benefits and how they are accessed.

It is important to understand what you are entitled to under your Long Term Care Policy. More important than understanding your Long Term Care Benefits is how to actually access those benefits.

Even when you are armed with accurate information, and thoroughly understand your policy, some insurers have been known to act inappropriately. Here is an article I found with a quick google search:

Florida nurse registry claims insurer improperly denying benefits on long-term care policies

USA February 4, 2011

A class-action lawsuit filed by a Florida nurse registry claims that Transamerica Life Insurance Company’s (Transamerica) long-term care insurance policies improperly deny coverage by requiring a level of certification for home health aides that exceeds state requirements and that Florida law does not allow Transamerica to deny coverage meeting those state requirements.

According to a complaint filed in the District Court for the Southern District of Florida on January 21, 2011, American Nursing Resources Inc. (American Nursing) arranges home health care services for clients, regularly receives insurance-benefit assignments from its clients, and bills insurance companies directly for its services.

American Nursing alleges that its home health aides have provided services to Howard Boteler since October 31, 2009. Mr. Boteler assigned American Nursing his benefits under a long-term care policy issued by a predecessor of Transamerica. American Nursing alleges that when it attempted to collect benefits under the policy,

 Transamerica denied its claim on the basis that the services were not provided by a “Home Health Aide” as defined in the policy. According to the complaint, the policy provided for reimbursement for the services of a “Home Health Aide” if the aide was: (1) eligible for reimbursement under Medicare; (2) employed by a state-licensed or accredited home health care agency; or (3) employed by a provider of home health care services accredited by the National League of Nursing, American Public Health Association, or the Joint Commission on Accreditation of Hospitals.

American Nursing alleges that, by its definition of “Home Health Aide,” Transamerica effectively requires a nurse registry such as American Nursing to either: arrange for the provision of basic services by nurses or other individuals with a level of certification greater than that of a home health aide; become eligible for reimbursement under Medicare; or be licensed as a “Home Health Care Agency.” 

American Nursing alleges that this violates Florida statutes governing long-term care insurance, which provide that a long-term care policy cannot: require services to be performed by an individual with a higher level of certification than the services require; require services to be provided by a licensed home health agency when they can be provided by a nurse registry, or require that services be required by Medicare-certified agencies or providers. See FLA. STAT. ANN. § 627.94071.

The complaint alleges that “Defendant cannot define ‘Home Health Aide’ and implement its policy in a manner which violates Florida law by excluding or discriminating against nurse registries as covered home health service providers for basic services. … To do so, violates the Florida Statutes and Rules which by law are incorporated into Defendant’s Policy and give rise to an action for breach of the Policy.”

American Nursing seeks, for itself and on behalf of similarly situated providers, damages for breach of contract and an injunction preventing further denial of benefits on these grounds. 

American Nursing has defined the class narrowly to include only Florida licensed nurse registries which, from January 1, 2006, through January 21, 2011, were assignees under a Transamerica long-term care policy and had a claim for benefits for home health-care services provided in Florida denied on the basis that the services were not provided by a “Home Health Aide” under the policy. 

The class is also defined to include any Florida-licensed nurse registries currently named as assignees under such a policy. The case is American Nursing Resources, Inc., v. Transamerica Life Insurance Company, No. 0:11-cv-60146 (S.D. Fla.)

Are issues with long-term care insurance common?

Unexpected issues with long-term care insurance are more common than many think.

The situation described in the article above has occurred with a State Farm Long Term Care Insurance Policy a client of Abby Services has. As long-term care insurance experts, we are helping them to work through the insurer’s confusion and hopefully, State Farm will do the right thing.

What do you mean "hopefully the long term care insurance provider will do the right thing"?

 

Doing the “right thing” would be allowing a claimant to easily and appropriately access the long-term care insurance policy they have paid for as required by law. The specific law the article references is listed below. 

Florida Statute 627.94071 which covers life insurance for seniors contracts and rates:

627.94071 Minimum standards for home health care benefits.A long-term care insurance policy, certificate, or rider that contains a home health care benefit must meet or exceed the minimum standards specified in this section. The policy, certificate, or rider may not exclude benefits by any of the following means:

(1) Providing that home health care cannot be covered unless the insured or claimant would, without the home health care, require skilled care in a skilled nursing facility.
(2) Requiring that the insured or claimant first or simultaneously receive nursing or therapeutic services in a home setting or community setting before home health care services are covered.
(3) Limiting eligible services to services provided by registered nurses or licensed practical nurses.
(4) Requiring that a nurse or therapist provide services covered by the policy that can be provided by a home health aide or by another licensed or certified home care worker acting within the scope of his or her license or certification.
(5) Requiring that a licensed home health agency provide services covered by the policy that can be provided by a nurse registry licensed under chapter 400.
(6) Excluding coverage for personal care services provided by a home health aide.
(7) Requiring that the provision of home health care services be at a level of certification of licensure greater than that required by the eligible service.
(8) Requiring that the insured/claimant have an acute condition before home health care services are covered.
(9) Limiting benefits to services provided by Medicare-certified agencies or providers.
(10) Excluding coverage for adult day care services.
  

Do you have a long-term care insurance complaint?

If you are confused about your policy or believe you are being inappropriately denied long-term care insurance benefits you are entitled to you should review the Florida Department of Financial Services website. They are the entity best suited to help resolve most long-term care insurance issues.
 
Sometimes, despite attempts to educate insurance providers on regulations in our state, (regulations that they should already be familiar with) you need an attorney familiar with specific state laws, to help fight for the benefits you are entitled to. Below is an attorney you may want to consider.
 
Stephen Dunn
Phone: (410) 321-8368
Email: sdunn@smdunnlaw.com

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