Genworth LTC Claim Denial

[JosephDeacon]

I have a friend who contacted me who is trying to help his uncle with an LTC claim. His uncle has a unlimited benefit Genworth LTC plan with a 30 day waiting period. He had a pacemaker installed 2 months ago and is having difficulty with at least 3 ADL's and was examined by Genworth's nurse. The nurse told him that he should have no issue getting the claim approved. The claim was then denied.

What should his next course of action be?

I told him to have his uncle contact the agent as the agent should be assisting with the claim process.

Any help is appreciated, thanks guys and gals.

 

[moonlightandmargaritas]

What should his next course of action be?

I told him to have his uncle contact the agent as the agent should be assisting with the claim process.

As you have no way to assess the ability/knowledge level (if they're still in the business, that is) of the agent, I would skip that step, and make sure the claim appeal process (in writing of course, with a copy to the relevant state's DOI) is started right away.

Most states have a statutory limit on settling claims, and you want to get the clock ticking as soon as possible!

 

[Bob_The_Insurance_Guy]

One call to PrePaid Legal, and have their attorney call on his behalf.

 

[Mr_Ed]

I have a friend who contacted me who is trying to help his uncle with an LTC claim. His uncle has a unlimited benefit Genworth LTC plan with a 30 day waiting period. He had a pacemaker installed 2 months ago and is having difficulty with at least 3 ADL's and was examined by Genworth's nurse. The nurse told him that he should have no issue getting the claim approved. The claim was then denied.

What should his next course of action be?

I told him to have his uncle contact the agent as the agent should be assisting with the claim process.

Any help is appreciated, thanks guys and gals.

They can't just deny a claim and not give a reason.

What was the reason for the denial?
- - - - - - - - - - - - - - - - - -
I'll bet $100 that the claim was "denied" because the medical records were not sent to Genworth from the doctor's office before the 90-day deadline.

 

[insurehound]

It's a tax qualified plan right? Tax qualified plans say that your doctor must certify that you will not be able to do 2 out of 6 ADLs for 90 days or longer. In short it has to be a chronic condition lasting longer than 90 days. The 30-day waiting period is only good if your doctor certifies that you will need care lasting longer than 90 days.

But there has to be a reason given for the denial. Your friend should get a copy of the denial letter and go from there. Remember, claims are paid based on the contract. So I would review the contract to make sure the insurance company is correct. If not, call the DOI immediately.

 

[Mr_Ed]

The vast majority of claims that are initially "denied" are approved after the medical records are finally sent to the insurer.

The insurers have a time limit by which they have to make a claims decision. If the medical records are not received within that time-frame, they have to deny the claim because they did not receive the medical records.

Once the medical records are received the claim is re-opened.

 

[insurehound]

The vast majority of claims that are initially "denied" are approved after the medical records are finally sent to the insurer.

The insurers have a time limit by which they have to make a claims decision. If the medical records are not received within that time-frame, they have to deny the claim because they did not receive the medical records.

Once the medical records are received the claim is re-opened.

Good point.

 

[HelpingPeople]

I have a friend who contacted me who is trying to help his uncle with an LTC claim. His uncle has a unlimited benefit Genworth LTC plan with a 30 day waiting period. He had a pacemaker installed 2 months ago and is having difficulty with at least 3 ADL's and was examined by Genworth's nurse. The nurse told him that he should have no issue getting the claim approved. The claim was then denied.

What should his next course of action be?

I told him to have his uncle contact the agent as the agent should be assisting with the claim process.

Any help is appreciated, thanks guys and gals.

Look at the POLICY. It should indicate if it is the client's doctor or the companies doctor who determines if 3 ADLs are valid. Also, the call should have been made on the first day to Genworth to "register" the Long Term Care event that "may" have triggered the the claim. If the waiting period is met from the date of the call to Genworth, then the claim should be accepted; however, only a designated person as described in the policy can determine if enough ADLs are qualified. For Genworth, I believe it is 2 of the 6 ADLs, but you should always refer back to the policy for this definition.

 

[Mr_Ed]

Look at the POLICY. It should indicate if it is the client's doctor or the companies doctor who determines if 3 ADLs are valid. Also, the call should have been made on the first day to Genworth to "register" the Long Term Care event that "may" have triggered the the claim. If the waiting period is met from the date of the call to Genworth, then the claim should be accepted; however, only a designated person as described in the policy can determine if enough ADLs are qualified. For Genworth, I believe it is 2 of the 6 ADLs, but you should always refer back to the policy for this definition.

There is no long-term care insurance policy that requires an "insurance company doctor" to be the only one who can certify if someone is eligible for benefits.

There is no long-term care insurance policy that will pay a claim simply because the claimant's doctor certifies that he/she needs assistance with 2 of the 6 ADL's.

Every long-term care insurance policy allows for the policyholder's doctor to initiate the claims process by certifying that he/she needs assistance with 2 of the 6 ADL's. But every policy also allows for the insurer to verify the doctor's certification by reviewing the claimant's medical records, and, if need be, having their own medical professional examine the claimant.