legallearner
Junior Member
What is the name of your state (only U.S. law)? WA
My mother lives in a retirement community that offers “ala carte” assisted living services. The base level is really nothing more than having the paperwork on file in case more services are needed, or to have access to the nurse. There are several additional layers to the ala carte services, each building upon this bare bones/paper-on-file plan.
The community does not have an “AL ward” – instead, each resident’s apartment is categorized as “independent” unless they have paperwork on file with AL, and then the apartment is considered “licensed” so that the AL staff has legal authority (for liability reasons) to go into it or treat the resident who occupies it. The Al staff will not set foot in an unlicensed apartment or tend to a resident of an unlicensed apartment, even if it is to look at a wound.
For a medical reason, we put my mother on the AL services for one month as a safety net (that is, her apartment was technically “licensed” so Al staff could go in). It was more to have access to the nurse if she needed it, since she was recovering. She was considered completely recovered, however, and had just been discharged from Medicare’s Home Health services. But, we wanted that healthcare access since I am her only relative and caregiver and I do not live close. So, being able to see an onsite nurse or medically trained professional if something came up rather than calling a cab to take her to urgent care somewhere seemed to make sense.
As the month went by, we realized my mother did not need the AL services. She had not used them at all, and the AL director deemed her “independent” from their initial and subsequent assessments (one while being evaluated for upcoming AL, the other being on the start date of being on the AL roster), therefore not needing their help or services or a care plan. So, we discontinued AL for my mother to be effective on the 23rd of that month.
Concurrently, we were looking at long term care insurance policies for my mother. The application my mother completed and signed had a question: “In the past 5 years has anyone proposed for insurance been treated for drug or alcohol abuse or abused alcohol or drugs or had abnormal test results relating to alcohol or drug use or are currently confined to an assisted living facility or nursing home?”
She answered “no”. By all accounts, including by the AL director and nurse, my mother’s doctor, and by Medicare’s Home Health definition, my mother was not “confined” to assisted living. Not only was she deemed independent, she was out and about on her own and definitely not confined.
My mother signed and dated the application on the 23rd of that month, the same date that we requested AL be discontinued… again, as far as the question goes, we didn’t even consider her to be on AL services since we had discontinued them. If we had, she would have held off on signing and dating the application for 7 days until the first of the following month. And the net of it is that no services were ever used, so “no”, she was not even using AL services on that date or prior or after if that was the question.,
We recently filed a claim. The insurance company is paying out a lower level of benefits than sought (would require a lot more detail), but I want to push for the benefit level I think my mother deserves (I am her attorney-in-fact). I talked with the agent who sold us this policy, and he said that the insurance company could cancel the entire policy because it might be considered that my mother was using AL services on the 23rd when the application was signed since her apartment was licensed that day.
My questions are: isn’t the operative word to the application question “confined”? Medicare would not have considered her “confined”. Her doctor would not consider her “confined”. She certainly was not in anyone’s view and the AL director offered to write a letter stating such. Plus, we requested that my mother be discontinued from Al on the 23rd. She had never used the services. Does it matter that her apartment was technically "licensed" so an AL staffer could go in? Again, no confinement or any use of services-- in fact, we took a weekend getaway together, so her licensed apartment sat empty for a bit.
In a sort-of Catch-22, because she didn’t use or need AL services during that time period, there are no records of care or visits or anything for her… so a “discontinued” date was never recorded on the AL records – in their view nothing was done so nothing needed to be discontinued. The only records AL has are from the two assessments. However, my accounting records show that I asked for AL to be discontinued on the 23rd, and this was told to the community’s accountant (but I don’t know if the accountant has a record as AL services are paid for a month in advance and do not get prorated retroactively).
I believe and would take an oath in court that the question was answered truthfully.
Can I feel comfortable pushing for the higher level of benefits without fear that they will cancel the policy due to what the agent says is focusing on the word “currently” yet I believe “confined” is the operative one. (And, again, technically the Al services were discontinued that day and actually never used anyway).
Thank you. I hope this made sense.
My mother lives in a retirement community that offers “ala carte” assisted living services. The base level is really nothing more than having the paperwork on file in case more services are needed, or to have access to the nurse. There are several additional layers to the ala carte services, each building upon this bare bones/paper-on-file plan.
The community does not have an “AL ward” – instead, each resident’s apartment is categorized as “independent” unless they have paperwork on file with AL, and then the apartment is considered “licensed” so that the AL staff has legal authority (for liability reasons) to go into it or treat the resident who occupies it. The Al staff will not set foot in an unlicensed apartment or tend to a resident of an unlicensed apartment, even if it is to look at a wound.
For a medical reason, we put my mother on the AL services for one month as a safety net (that is, her apartment was technically “licensed” so Al staff could go in). It was more to have access to the nurse if she needed it, since she was recovering. She was considered completely recovered, however, and had just been discharged from Medicare’s Home Health services. But, we wanted that healthcare access since I am her only relative and caregiver and I do not live close. So, being able to see an onsite nurse or medically trained professional if something came up rather than calling a cab to take her to urgent care somewhere seemed to make sense.
As the month went by, we realized my mother did not need the AL services. She had not used them at all, and the AL director deemed her “independent” from their initial and subsequent assessments (one while being evaluated for upcoming AL, the other being on the start date of being on the AL roster), therefore not needing their help or services or a care plan. So, we discontinued AL for my mother to be effective on the 23rd of that month.
Concurrently, we were looking at long term care insurance policies for my mother. The application my mother completed and signed had a question: “In the past 5 years has anyone proposed for insurance been treated for drug or alcohol abuse or abused alcohol or drugs or had abnormal test results relating to alcohol or drug use or are currently confined to an assisted living facility or nursing home?”
She answered “no”. By all accounts, including by the AL director and nurse, my mother’s doctor, and by Medicare’s Home Health definition, my mother was not “confined” to assisted living. Not only was she deemed independent, she was out and about on her own and definitely not confined.
My mother signed and dated the application on the 23rd of that month, the same date that we requested AL be discontinued… again, as far as the question goes, we didn’t even consider her to be on AL services since we had discontinued them. If we had, she would have held off on signing and dating the application for 7 days until the first of the following month. And the net of it is that no services were ever used, so “no”, she was not even using AL services on that date or prior or after if that was the question.,
We recently filed a claim. The insurance company is paying out a lower level of benefits than sought (would require a lot more detail), but I want to push for the benefit level I think my mother deserves (I am her attorney-in-fact). I talked with the agent who sold us this policy, and he said that the insurance company could cancel the entire policy because it might be considered that my mother was using AL services on the 23rd when the application was signed since her apartment was licensed that day.
My questions are: isn’t the operative word to the application question “confined”? Medicare would not have considered her “confined”. Her doctor would not consider her “confined”. She certainly was not in anyone’s view and the AL director offered to write a letter stating such. Plus, we requested that my mother be discontinued from Al on the 23rd. She had never used the services. Does it matter that her apartment was technically "licensed" so an AL staffer could go in? Again, no confinement or any use of services-- in fact, we took a weekend getaway together, so her licensed apartment sat empty for a bit.
In a sort-of Catch-22, because she didn’t use or need AL services during that time period, there are no records of care or visits or anything for her… so a “discontinued” date was never recorded on the AL records – in their view nothing was done so nothing needed to be discontinued. The only records AL has are from the two assessments. However, my accounting records show that I asked for AL to be discontinued on the 23rd, and this was told to the community’s accountant (but I don’t know if the accountant has a record as AL services are paid for a month in advance and do not get prorated retroactively).
I believe and would take an oath in court that the question was answered truthfully.
Can I feel comfortable pushing for the higher level of benefits without fear that they will cancel the policy due to what the agent says is focusing on the word “currently” yet I believe “confined” is the operative one. (And, again, technically the Al services were discontinued that day and actually never used anyway).
Thank you. I hope this made sense.