Shots - Health News
1:49 am
Wed October 17, 2012

States Iron Out The Kinks In Long-Term Care Insurance

Originally published on Wed October 17, 2012 6:31 am

Long-term care insurance provides money for care when you're too old or sick to wash yourself and cook, though few American use it. Many who do have found that some insurance companies are slow to pay up or deny payments completely.

Oregon is one of several states that's adopting new regulations to improve the industry.

It used to be that the only way to appeal a long-term care decision in Oregon was in court, an arduous process for a person who may be elderly, sick or in a nursing home.

Oregonians now have the right to get an undisputed claim paid within 30 days, thanks to new legislation. They also have a right to an appeals process, says Cheryl Martinis with the state's consumer services department

Jim Chenoweth had to call on the Oregon insurance commissioner's office recently to get a claim paid. Chenoweth decided to get long-term care insurance a few years ago after he'd spent time caring for his ailing wife.

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

After Chenoweth had a couple of falls, his daughter, Joyce, hired a woman to come in to help him shower. But when they tried to make a claim, their insurance company gave them the runaround. She says both she and her father got very frustrated.

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

The whole process was long and confusing, says Joyce. "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 works at the Oregon Insurance Commission call center as a consumer advocate, helping people negotiate with their insurance companies and find their way around 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.

"Another example is sometimes we'll hear from a family member that has found the perfect home, residential home or long-term care facility for Mom," Lefferts says. "But the home, according to the insurance company, doesn't meet the credentialing requirements in terms of its licensure by the state."

And the problem isn't confined to just Oregon. The National Association of Insurance Commissioners has come up with model legislation for the states. Sandy Praeger is the association's chairwoman and the insurance commissioner for Kansas.

"We do have problems with companies that sometimes delay payment. They lose the paperwork," Praeger says. "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.

And what about the woman whose mother moved into a care facility that wasn't licensed by the state? The insurance company shouldn't pay, he says.

"If you make an exception for one person, you then have set precedent," Slome says, "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.' "

This piece is part of a partnership with NPR, Oregon Public Broadcasting and Kaiser Health News.

Copyright 2013 Oregon Public Broadcasting. To see more, visit http://www.opb.org.

Transcript

STEVE INSKEEP, HOST:

Now let's talk about long-term care insurance, which helps to pay for nursing homes or in-home care when you're too old or too sick to look after yourself. It's not something that many people sign up for. The premiums are expensive. So many people work on the assumption that their children will look after them when the time comes.

But there is another problem, too. Some insurance companies are very slow to pay out, and even deny payments completely. As Kristian Foden-Vencil of Oregon Public Broadcasting reports, this has prompted several states to adopt new regulations.

KRISTIAN FODEN-VENCIL, BYLINE: Until now, the only way to appeal a long-term care insurance claim in Oregon was in court. As you can imagine, if you're elderly, sick and you've just moved into a nursing home, a convoluted court battle is probably the last thing you need. So Cheryl Martinis with the state's consumer services department says they set up a new appeals process to determine when claims are wrongfully denied.

CHERYL MARTINIS: In the past, with long-term care insurance, consumers haven't had the same rights that they've 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. Also, we haven't had an appeals process in the past, and now we do.

(SOUNDBITE OF TV SHOW)

FODEN-VENCIL: Jim Chenoweth sits in the comfy folds of his armchair watching TV. A few years ago, after caring for his sick wife, he decided to get long-term care insurance.

JIM CHENOWETH: I didn't want to have my kids or anybody else have to take care of me.

FODEN-VENCIL: Recently, he's had a couple of falls. So his daughter, Joyce Chenoweth, hired a woman to come in to help him shower. But Joyce says, 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.

JOYCE CHENOWETH: They kept messing around with me. I mean, they kept, they say, you know, I'll do this, I'll do this, I'll do this and they never did anything.

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

FODEN-VENCIL: The whole process was long and confusing, Joyce Chenoweth 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.

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

(SOUNDBITE OF RINGING PHONE)

SUE LEFFERTS: This is Sue, how may I help you?

FODEN-VENCIL: Sue Lefferts works at the Oregon Insurance Division call center. She's a consumer advocate, so she helps people negotiate with their insurance companies and use 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.

LEFFERTS: Another example is sometimes we'll hear from a family member that has found the perfect home, residential home or long-term care facility for Mom. But the home, according to the insurance company, doesn't meet the credentialing requirements in terms of its licensure by the state.

FODEN-VENCIL: And the problem isn't just confined to Oregon. The National Association of Insurance Commissioners has come up with model legislation for the states.

Sandy Praeger is the association's chair and the insurance commissioner for Kansas.

SANDY PRAEGER: We do have problems sometimes with companies that delay payment. They lose the paperwork. 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.

FODEN-VENCIL: But those benefits are outlined in consumer contracts, say the insurance companies. And they have to be adhered to.

Jesse Slome is with the American Association for Long-Term Care Insurance.

JESSE SLOME: 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 as a qualified claim.

FODEN-VENCIL: And what about the example where someone's mother moves into a care facility that isn't licensed by the state but she likes it and doesn't want to move? He says the insurance companies won't pay.

SLOME: If you make an exception for one person, you then have set precedents, you have to make the exception for everybody, who says, listen, I've decided I want my care on a cruise line, you know.

(LAUGHTER)

SLOME: And so now, pay up.

FODEN-VENCIL: Many states, like Alabama, California and Nebraska, have adopted one or more of the regulations recommended by the National Association of Insurance Commissioners. But some states, like Alaska, have largely ignored them.

For NPR News, I'm Kristian Foden-Vencil in Portland.

INSKEEP: And his report is part of a partnership with NPR, Oregon Public Broadcasting and Kaiser Health News.

(SOUNDBITE OF MUSIC)

INSKEEP: It's MORNING EDITION from NPR News. Transcript provided by NPR, Copyright NPR.

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