Long-term care insurance is the financial equivalent of doing push-ups — it’s good for you, but not too much fun.
As a result, not many people buy long-term care insurance, which pays for care when they get too old or sick to take care of their basic needs like cooking or bathing. The insurance is expensive, and most people hope they will never need it or that their children or other family members will look after them instead.
But long-term care insurance has another problem too: Some insurance companies are slow to pay and have been known to deny payments completely.
Many states, including Oregon, Kansas, and Alabama, are adopting new regulations to give consumers some help.
Oregon, for example, has new rules on how to appeal a denial on a long-term care insurance claim. Previously, the only way to appeal a decision was in court, an arduous process for a person who may be elderly, sick and in a nursing home.
Cheryl Martinis, with the state’s consumer services department, says Oregon set up a new appeals process to determine when claims are wrongfully denied.
“In the past with long-term care insurance, consumers haven’t had the same rights that they have had with other health insurance,” Martinis explains, “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.”
Jim Chenoweth had to call on the Oregon insurance commissioner’s office recently to get a claim paid. Chenoweth, 81, decided to get long-term care insurance a few years ago after he had spent time caring for his ailing wife.
“I didn’t want to have my kids or anyone else take care of me,” says Chenoweth, who estimates he’s paid about $30,000 in premiums.
After Chenoweth had a couple of falls, his daughter, Joyce Chenoweth hired a woman to come in to help him shower, but when they tried to make a claim, their insurance company gave them the run-around. She says both she and her father got very frustrated.
“They kept messing around with me,” Joyce Chenoweth says. “They said, ‘I’ll do this, I’ll do this, I’ll do this,’ and they never did anything.”
Jim Chenoweth also had his share of calls to the insurer. “They kept passing the buck back and forth, back and forth,” he says. “I got upset, my daughter got upset and we finally got a hold of the insurance commission and then they started getting it together.”
The whole process was long and confusing, says Joyce Chenoweth. “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.
Sue Lefferts, who works at the Oregon Insurance Division call center as a consumer advocate, helps people negotiate with their insurance companies and navigate the new appeals process. Some of the more common complaints she says, are that insurance companies don’t think claimants are sufficiently incapacitated to need help, or that the person hasn’t filed the right paperwork.
“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.
And the problem isn’t just in Oregon. The National Association of Insurance Commissioners has come up with model legislation for the states.
“We do have problems with companies that sometimes delay payment. They lose the paperwork,” says Sandy Praeger, the association’s chairwoman and the insurance commissioner for Kansas. “But I think that’s what state departments of insurance are there for and that’s to help people get the benefits they’re entitled to.”
But those benefits are outlined in consumer contracts, say the insurance companies. And the fine print has to be adhered to.
“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,” says Jesse Slome, with the American Association for Long-Term Care Insurance.
For example, he says, he recently talked to a woman whose mother moved into a care facility that wasn’t licensed by the state. But she liked the home and didn’t move — so the insurance company didn’t pay.
“If you make an exception for one person, you then have set precedents, 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.