Just because you have a denial in hand, doesn’t mean the policy is never going to pay.

There are only 3 reasons claims are ever denied, and most cases can be corrected
eventually (though it can take some serious time and energy to make that happen…).

Here are the 3 reasons claims are denied and the most common fixes:

1) You have the wrong type of care giver. We run into this one most often in two scenarios

a. The care giver is not licensed – most reimbursement contracts require a licensed care provider. Home care in particular is often conducted by companies who do not have a state license (because states don’t require it, actually…not because they are operating improperly). Nevertheless, if your contract requires a licensed care provider, or has the language “home health agency”, then you will have to hire a licensed home health agency in order for that care giver to be approved under the contract.

b. You want home care when the policy is facility only (or vice versa). There is almost no hope in this case. You again have to “knuckle under” and go with the care giver it will approve. I have listened to people heatedly argue that home care is going to be so much cheaper than being in a nursing home so the insurance company really ought to pay for home care even though the contract is nursing home only (and vice versa). Wrong. The insurance company doesn’t have to pay for anything that is not in the contract. They will honor the contract—faithfully. Right. To. The. Letter. So you may as well not waste a lot of energy trying to get the contract to pay for something it won’t. It is not going to happen. My favorite analogy on this is that if you bought a red car, you are driving a red car. You can’t make it become a blue truck. If you bought home care only, then you have home care only (and vice versa).

c. Alternate plan of care – once in a great while there will be a door way you can get thru that mentions alternate plan of care. The language in these is crucial and comes with wide variation. So, if in doubt, set up a time to speak to one of our long term care specialists. They can help you know if you have any chance thru this obscure and highly-variable door for alternate types of care providers.

2) You are not medically eligible yet.

This one is tricky because I have seen people who need care (say someone has macular degermation and is legally blind – clearly they need care as they can’t shop, cook, drive, or even tell medications apart any more), but are fully able to do all of their activities of daily living on their own and don’t have any cognitive deficits. I have also seen people who need some minor help at their homes or in the assisted living and need help with only one activity of daily living (usually bathing). So if they are only 1 ADL (activity of daily living) down, then they are probably not yet medically eligible. However…, typically most seniors are not really only 1 ADL down. If they need help bathing, then chances are they actually need help with something else (shoes and socks, maybe? Or transferring in/out of a car because the seat is so low?). So if a person is needing help on 1 ADL, then the denial is more likely because of #3 below.

3) Wrong or incomplete documentation.

The reasons for this can be legion… Maybe the fax broke part way and so out of the 102 pages the rehab sent to the insurance company, only 48 of them got thru and the relevant information needed was in page 50 thru 60 that didn’t make it thru. Or maybe someone forgot to mark a box on the form. Or maybe the doc only knows that you have Parkinson’s and has no idea if you need help showering or dressing or toileting and so leaves all of that blank. Or maybe when the nurse assessor came out to interview the policy holder, the policy holder did not tell the truth because s/he did not want to tell a stranger just how weak and needy s/he was. This is far and away the most common reason someone is denied.

The good news is that this also fixable. Notice I did not say it was easy to fix -- just that it is fixable.

If you truly think this could be the problem, we recommend you read the book we have on claim filing

Or that you set up a time to speak with one of our long term care insurance specialists. The first half hour conversation is at no charge. CLICK HERE TO SCHEDULE APPOINTMENT


MRS.LTC is excited to introduce and new way to help in the claim process! While our staff can certainly help you craft an appeal, we charge $150 to do that with you. This DIY module allows you to do the same for half the cost.



Package Includes:

- How to File an Appeal of a Declined Claim
- Appeal Request Template
- Doctor Letter Template ADL
- Doctor Letter Template Cognitive Loss



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