State Creates Long-Term Care Insurance Appeals Process ? OPB ...

Kristian Foden-Vencil | July 27, 2012 6 a.m. | Updated: July 27, 2012 7:28 a.m. | Portland, OR

If you're younger than 45, you probably haven't thought much about long-term care insurance.

Basically, it provides money to pay for in-home or nursing home care when you're too infirm or sick to cook or wash yourself.

Until now, the only way to appeal if your insurance claim was denied, was in court. That can be an?expensive and convoluted process -- especially if you're elderly.

But now Oregon has set up a new long-term care appeals process to determine when claims are wrongfully denied.

Jim Chenoweth sits in the comfy folds of his recliner watching TV. He spent 40 years as an iron worker and several years in the military, including service in Korea.

A few years ago, his wife had a stroke that left her incapacitated.

Kristian Foden-Vencil / OPB

Jim Chenoweth

Chenoweth says finding help while she was still alive was very difficult and expensive. So he decided he'd get long-term care insurance for himself.

"I didn't want to have my kids of anyone else take care of me," Chenoweth says.

Since then, Chenoweth estimates he's paid about $30,000 in premiums.

His daughter, Joyce Chenoweth, says last year, Jim had a couple of falls, so they hired a woman to come in twice a week -- to help him shower. But Joyce says, when they tried to make a claim, their insurance gave them the run-around.

"They kept messing around with me. I mean they said, I'll do this, I'll do this, I'll do this and they never did anything," Joyce Chenoweth says.

So, she had to take the next step.

Joyce Chemoweth: "Finally, I filed a complaint and within a month, we had our money."

Jim Chenoweth: "They kept passing the buck back and forth, back and forth. And I got upset, my daughter got upset and we finally got a hold of the insurance commission and then they started getting it together."

Joyce Chemoweth: "I just don't know how older people can figure this stuff out, when it took me months and months and months."

Last year, the Oregon Insurance Division estimates it fielded about 100 complaints about long-term care insurance.

"Oregon Insurance Commissioners officer, consumer advocacy, this is Sue, how may I help you?" Lefferts says.

Kristian Foden-Vencil / OPB

Sue Lefferts

Sue Lefferts works at a call center with the state. She helps people negotiate with insurance companies. She says some of the more common complaints are that an insurance company doesn't think a claimant is sufficiently incapacitated to need help, or the person hasn't filed ?the right paperwork.

"I wouldn't say the insurance companies are running rampant, but we are seeing more and more people who are making claims under these policies and so it's kind of brought to the forefront," Lefferts says.

In fact, the National Association of Insurance Commissioners has come up with several suggestions for states to deal with this issue, and Oregon is looking at this recommendations.

Cheryl Martinis of the Oregon Department of Consumer and Business Services, says this month, Oregon opened a new system to deal with appeals and prompt payment.

"In the past with long-term care insurance, consumers haven't had the same rights that they have had with other health insurance, and that is to have an undisputed claim paid within 30 days, and so now that is a right in Oregon. And also, we haven't had an appeals process in the past, and now we do," according to Martinis.

The new process involves hiring a private company that listens to consumers and insurance companies -- and then decides the case.

The insurance companies pay the cost of the review. But says Martinis, great care is taken to guarantee objectivity.

"The insurance division basically certifies that these companies, and these are nationwide companies that do this across the country, they certify that they've met the qualifications, they have adequate staff with the right expertise to make these decisions, and they take a look at the case."

Jesse Slome is with the American Association for Long-Term Care Insurance. He says insurance companies sometimes have good reasons to deny or delay claims.

"Often individuals submit incomplete paperwork. Or they don't read their policy or talk to the insurance company to find out exactly what's qualified for a qualified claim."

For example, he says, he recently talked to a woman whose mother moved into a care facility that wasn't licensed. She liked the home and didn't want to move, so the insurance company didn't pay.

"If you make an exception for one person. You then have set precedence and you have to make the exception for everybody, who says, 'Listen, I've decided I want my care on a cruise line. And so now, pay up'," Slome says.

Many states are opening appeal centers like Oregon's. But still, not many people get long-term care insurance. The state estimates only about six percent of Oregonians over 45 buy it.

One of the reasons may be that it's not cheap. According to Slome, a 55-year-old couple can get $340,000 worth of coverage for about $225 a month -- but they have to be healthy to get rates that low.

The older you are, the more expensive it is. ?And if you're sick, the insurance company does not have to offer you coverage.

In fact, the Obama Administration tried to include new voluntary options for long-term care insurance in the Affordable Care Act. But health secretary Kathleen Sebelius told Congress her department didn't see a viable path for it at that time.

Back in southeast Portland Jim Chenoweth pets his dog and watches TV. He's pleased he decided to get insurance -- even if it did take him several months and a stern letter to get paid.

"I think it's a really good idea, really. Because if something happened to you, and say your family's not really well off or whatever okay, and something happened to you and you have to go into a rest home. Your social security is not going to take care of it. So you should have something to help you so your family doesn't have to be, a burden for them," Chenoweth says.

The state estimates the average cost of hiring someone to help out around the house five days a week is $47,000 a year, while nursing home care averages about $82,000 a year.

http://www.aaltci.org

http://www.naic.org

http://insurance.oregon.gov/consumer/long-term-care/long-term-care-info.html

Source: http://news.opb.org/article/state-creates-long-term-care-insurance-appeals-process/

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