Long-Term Care Insurance Companies Criticized for Denying Claims

An article in the March 27, 2007, issue of The New York Times describes the practice of some insurance companies setting up bureaucratic barriers to the filing of claims for coverage in order to save money.  The article focused on three companies, Conseco, Penn Treaty, and Banker's Life and Casualty, which appear to purposely create roadblocks to coverage claims.  Complaints about Conseco number one for every 383 of its policies, which is a whopping 32 times the rate of complaints received by the largest long-term care insurance provider, Genworth Financial.  Penn Treaty receives complaints at a rate 10 times that of Genworth.

We recently had a client with a related issue, the practice of insurance companies to terminate policies if the premium payment arrives late.  Our client had been hospitalized when the premium was due and her niece had the bill paid after collecting mail from the client's home.  The client received a check back from the insurance company saying that payment had arrived late and that therefore the company could not reinstate the policy.

A review of the policy itself indicated that this form letter misstated its terms.  In fact, the insurance company had discretion to reinstate the policy despite late payment.  I explained this to the person I reached at the company, who was unmoved by my arguments.  So I asked to speak to his supervisor.

She was quite pleasant and said she would look into the matter and get back to me, which she did.  Her investigation revealed that the company had in fact received the client's premium check on the last day of the grace period, which happened to be a holiday, so the check was deposited the following day, which was the reason the policy was terminated.  She reinstated the policy.

The good news in this story is that our client still has long-term care insurance coverage and the company responded reasonably after not too much trouble -- unlike the stories described in the Times article at other companies.  However, the insurance company made a mistake, then sent a misleading letter, and did not respond to the first call for reconsideration.  A frail, elderly policy holder may not have persisted and had the results we achieved.

The morals of this story?  Be persistent.  Get help.  Don't by a policy from Conseco, Penn Treaty or Banker's Life.

Comments

[Scott A. Olson, CLTC]

Great post, Harry.

When you get past the 'hype', the real message of the NY Times article is NOT that the long term care insurance industry has failed. The long term care insurance industry, as a whole, has paid, and continues to pay, billions of dollars in long term care claims every year.

Thank you for the great job you are doing to help all our elders.

Scott A. Olson, CLTC
http://www.ltcinsuranceshopper.com/

[Julie Hurst]

A few bad apples always hurts the industry that is trying so dilligently to put a dent in the growing problem of funds for health care. The majority of LTCi companies are very good about claims, how else have we paid out over $3 billion in just 2006 alone! As I tell clients, stick to the top rated companies! Thanks for the article.

[Harry S. Margolis]

Another long-term care insurance professional who didn't want his name mentioned, commented as follows:

First of all, thank you for your balanced approach to the response to the NYT article on LTCI claim denials. The conclusion was a little tough on those companies in the article. I won't comment whether they deserved it or not.

Secondly, all LTCI policies now have a clause for reinstatement for an unintentional lapse. This clause adds five months to the normal 30-day grace period for a total of six months. this bacame a standard clause in the mid-90s with all companies. Normally companies will contractually limit this reinstatement due to an impairment with ADLs or a cognitive impairment. But my guess is that the case that you point out in your article would have qualified under this clause.

In the future, have your elder law brethren comb the contract looking for the unintentional lapse clause in a situation like the one that you describe. The "good" companies will recognize the argument and reinstate the policy with the payment of past due premium.

[EML]

Does anybody have claims experience with allianz or prudential?

[Bruce Miller]

I'm a Fee-Only Certified Fiancial Planner, and I also hold an insurance license in my state so that I can counsel clients on personal risk management.

Following some fairly extensive exploring of LTCI, I've concluded that it is not a product I would recommend very often, due to its current state of funding, future uncertainty and the 'outs' the insurer's have in denying future claims.

The LTCI concept is fine (prevent catestrophic loss of high-cost nursing home care and depletion of assets thus being religated to Medigap and its limitations). My problem is with the 'bad stuff'. To wit:

1. Future premium hikes. Most policies issued after HIPPA (1997) were woefully underpriced as a strategy to get market share, which for all but Hancock's Federal partnership no one was able to do. So all other things being equal, insurers are likely going to have to conduct some pretty hefty rate hikes in the years ahead.

2. No protection from default. Most states don't include LTCI in their State's Health Guaranty Fund...at least that I've been able to see. This means that if the insurer defaults, coverage, particularly for the older insured will be lost.

3. The need for active family participation. When most reach the point of being unable to perform the second ADL or are incompacitated by a cognative disorder, they're in no mental or physical condition to start battling it out with a recalcitrant insurer who has denied the claim (for whatever reason). Absent the active involvement of a family member (most likely the local adult child), denied claims run a high risk of never being processed through dispute resolution...and I suspect the insurers know this.

4. Determination of inability to do ADLs is borne by the insurer and the Occupational Therapists they hire. OT's have many ways to mitigate physical inabilities, such as velcro, spandex and the like.

5. Contract lanuage for QLTCI is probably the most agressive of all insurance contracts, due largely to the uncertain future of LTC disability, putting the insurer at greater risk. This risk is hedged through language that allows the insurer to prolong, delay and attempt rehab in some cases.

Clearly, the recalcitrance of the insurer will be governed by how much capital they have in reserve relative to projected claims rates. So if you think you really need LTCI, I'd stick with those who show the healthiest financial (capital) reserves, as they are the ones who will be less likely to deny your future claim and fairly rate the insureds ability to perform an ADL...but, of course, they are also the most expensive. These include companies like Genworth or Hancock.

[Medicare Supplement]

This is a very touchy subject and in many cases, the people have the right to complain.