What is the name of your state? Wisconsin
My Mother has a LTC policy that provides a long term care benefit, an alternative care facility benefit, & a home & community care benefit.
Policy Schedule Elimination Period is "90 days".
My mother received Agency home care services from 1/7/05-4/19/05 at which time service was interrupted. She received skilled nursing, PT, & personal care by a nursing assistant. She did not received services daily but during that time period did receive care at least twice weekly. By my calculations my mother met her elimination period as of 4/8/05.
The policy definition of elimination period specific to home & community care states, " The number of consecutive days of continuous home & community care for which no benefit is payable. The elimination period, if any, starts on the date that home and community care begins and is in effect for the number of days shown in the Policy Schedule."
The policy DOES NOT specifically define the terms consecutive or continuous, so I turned to my 2nd Edition American Heritage Dictionary which provides the following definitions.
Continuous: Extended or prolonged without interruption or cessation; unceasing.
Consecutive: Following successively without interruption; marked by logical sequence. follow closely.
o Successive: Following in uninterrupted order or sequence.
I would contend that the Agency provided continuous & consecutive care from 1/7/05 through 4/19/05 when the service was interrupted. I would contend that as of 4/8/05 the 90 day Elimination period was met.
The insurance company disagreed & stated, " The Elimination Period is based on the actual number of service days not calendar days."
The Policy Schedule DOES NOT define the elimination period as 90 service days , just 90 days.
While my mother's claim has been accepted, the claims examiner has been difficult to work with. It appears to me they do not want to pay the benefits to which she is entitiled to, by interpreting the elimination period in a way that is in their best interests.
Is their interpretation of the Elimination period acceptable Industry Standard, or should I request additional support, rationale or case law as to how they arrived at their interpretation since it is not so specifically defined in the Policy Schedule as 90 Service days.
In doing some research I learned that 14 complaints were filed against this LTC Company in 2004. Am I within my right to ask the company if any of those complaints concerned elimination period disputes, & if so how they were resolved?
I'm trying to determine if I should consult an attorney, file a dispute specific to the elimination period definition, or write to the Insurance Commissioner.
I did contact the agent who sold my mother the LTC policy, he said he would contact the Company to request additional information to clarify this issue, but to date he has not done so.
I'm trying to determine whether or not I have a legitimate complaint & if I do, what might be the most effective way to try & obtain satisfactory resolution.
My mother has paid her premiums in good faith & if she's entitled to benefits she should receive them.
Any advice or recommendations you can provide will be gratefully appreciated.
My Mother has a LTC policy that provides a long term care benefit, an alternative care facility benefit, & a home & community care benefit.
Policy Schedule Elimination Period is "90 days".
My mother received Agency home care services from 1/7/05-4/19/05 at which time service was interrupted. She received skilled nursing, PT, & personal care by a nursing assistant. She did not received services daily but during that time period did receive care at least twice weekly. By my calculations my mother met her elimination period as of 4/8/05.
The policy definition of elimination period specific to home & community care states, " The number of consecutive days of continuous home & community care for which no benefit is payable. The elimination period, if any, starts on the date that home and community care begins and is in effect for the number of days shown in the Policy Schedule."
The policy DOES NOT specifically define the terms consecutive or continuous, so I turned to my 2nd Edition American Heritage Dictionary which provides the following definitions.
Continuous: Extended or prolonged without interruption or cessation; unceasing.
Consecutive: Following successively without interruption; marked by logical sequence. follow closely.
o Successive: Following in uninterrupted order or sequence.
I would contend that the Agency provided continuous & consecutive care from 1/7/05 through 4/19/05 when the service was interrupted. I would contend that as of 4/8/05 the 90 day Elimination period was met.
The insurance company disagreed & stated, " The Elimination Period is based on the actual number of service days not calendar days."
The Policy Schedule DOES NOT define the elimination period as 90 service days , just 90 days.
While my mother's claim has been accepted, the claims examiner has been difficult to work with. It appears to me they do not want to pay the benefits to which she is entitiled to, by interpreting the elimination period in a way that is in their best interests.
Is their interpretation of the Elimination period acceptable Industry Standard, or should I request additional support, rationale or case law as to how they arrived at their interpretation since it is not so specifically defined in the Policy Schedule as 90 Service days.
In doing some research I learned that 14 complaints were filed against this LTC Company in 2004. Am I within my right to ask the company if any of those complaints concerned elimination period disputes, & if so how they were resolved?
I'm trying to determine if I should consult an attorney, file a dispute specific to the elimination period definition, or write to the Insurance Commissioner.
I did contact the agent who sold my mother the LTC policy, he said he would contact the Company to request additional information to clarify this issue, but to date he has not done so.
I'm trying to determine whether or not I have a legitimate complaint & if I do, what might be the most effective way to try & obtain satisfactory resolution.
My mother has paid her premiums in good faith & if she's entitled to benefits she should receive them.
Any advice or recommendations you can provide will be gratefully appreciated.
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