Filing a Complaint – to do or not to do?

ltc-claims-helpFiling a long term care claim can often be frustrating and a bit drawn out – it can also go quite smoothly. Since most people file only one or two of these in their lifetimes, it can be hard to know if your situation warrants a complaint to the insurance commissioner in your state. So… how do you know? And what is the advantage?

What’s the advantage of filing a complaint?

If you file a complaint with the Insurance Commissioner of the state where the person who needs care resides (note bene! Do not file in YOUR state…you have to file in the state where the claimant is), then this triggers a trained staff person (usually a lawyer) to write a formal inquiry to the carrier on your particular case. So, the more clearly you can state your complaint and the more evidence you provide to back it, the easier it is for this overworked staff person to draft the formal inquiry. Vague, unclear or undocumented complaints have very little likelihood of success. The formal inquiry, in turn, at the carrier takes the claim out of the offices of the normal claim adjudicators and puts it into the insurance carriers’ legal team. This team is empowered to make a decision different than the normal claim adjuster (who must follow company policies). So a complaint thru your insurance commissioner can sometimes expedite a claim that is stuck, overturn a claim denial and other happy outcomes. It can also net you nothing… but in general, when in doubt, file the complaint. After all, you won’t know if it will be helpful until you do it!

How do you know to file or not file a complaint?

  • The sooner the better. Complaints thru the insurance commissioner can take a while to work thru the process, so if you have an issue, file your complaint as soon as you can so that you can get a result as soon as you can.
  • Do not file a complaint if the carrier is within the specified contract guidelines to respond. Every contract will tell you how long the carrier has to make a determination on a claim. If you filed a month ago and still don’t have an answer, this is quite normal as most contracts give the carrier 60 to 90 days to respond.
  • Do not file simply because you want the policy to pay for a particular type of care (say home care) if the contract won’t cover that type of care (i.e. it is a facility only policy). A complaint will not get the carrier to honor benefits that are not covered in the contract.
  • Do file if there seems to be ambiguity in whether or not the policy covers a type of care. For instance, many older contracts would specify “intermediate or skilled care” – but modern vocabulary is “assisted living” and “skilled nursing care”. Usually “intermediate care” equals “assisted living” in today’s lingo. You have to verify elsewhere in the contract what is allowed as a “facility,” because maybe the assisted living doesn’t meet the contract guides of a “facility”.

If in doubt – file the complaint.

There are so many scenarios it isn’t possible to cover them all here. We can help with your specific questions regarding your long term care insurance claim. Give us a call. Our initial consultation is a no-cost, no-obligation conversation.

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