Handling the Nurse Assessment for a Claim

If you have read much on our website, you will be aware that one of the many ways and insurance company verifies the legitimacy of a claim is to have an independent nurse assessor interview the claimant. I find most people think this is a formality – well, it is not!

If the claimant does not tell the truth to this person (say, they simply “put their best foot forward” because they don’t want a stranger to know how fragile they have become…!), then the claim can be denied based on the results of this interview alone. You can appeal it, but it is much harder than just getting the interview done right the first time.

The nurse will ask the usual questions about whether or not a person needs help with a list of activities of daily living (usually these: bathing, dressing, toileting, incontinence, transferring to/from a bed or chair, and eating…meaning lifting a fork, not food preparation or shopping). They might also do a mini cognitive screen to see if there is apparent cognitive loss. From our point of view this always goes best if a family member or other advocate can be there for the claimant during the interview. This person can make sure accurate information is being provided and not “best foot forward” information.

Surprisingly, they sometimes ask other things, like, “Can you dial the number for emergency help?” By this they mean, “can you dial 911.” In fact we just recently had a claim denied because the claimant said they could dial 911 and then proved it by doing so…even though there was no emergency. Clearly a person should not dial 911 without an emergency! You’d think this alone would have indicated there was a cognitive processing problem. But the nurse report went back that the person was able to manage in an emergency and so the claim was denied. We fought back on this and won the day with a letter from the doctor.

I tell this story so you will know how seriously the insurance company regards the nurse’s assessment and report on his/her interaction with the claimant. Things that we might think are innocent statements (such as “oh, I can dress myself still”….even though it takes them nearly 4 hours as they have to rest after every article of clothing) are actually base-line criteria on which a claim is judged. This is not, by the way, the insurance company being picky. The insurance adjusters can only base a decision on the written documents they get. SO if we give false information (or information shaded just a little bit to make the claimant look mare able than s/he is!), it should be no surprise that we get a false claim denial. In the computer coding world the phrase is “garbage in, garbage out.” It is no less true here.

This is why we recommend someone always be with the claimant to make sure accurate information is being provided. It is also why we recommend someone manage the claim and monitor progress so that errors like this can be caught early and corrected long before the claim ends up in an irrevocable ditch!

Please reach out if we can be of any service. We believe strongly here at Mrs LTC that claimants should receive the benefits from the policies they own if they are truly claim eligible. Being denied because of wrong or incomplete information should never happen – but since it does, we hope the information and service we provide will help you overcome any such roadblocks!

Stana Martin, PhD, founded Mrs LTC to provide a top-quality resource for clients and customers who need help with long term care claims or insurance comparisons.