Long Term Care Horrible Experience W/Allstate

[Badandy1]

My experience with Allstate Long Term Care has. Been a nightmare! My father purchased a LTC in 1991.
The policy states that it covers nursing home care,
Nursing home defined as:
1) licensed 2) 24/7 nursing care under supervision of MD. 3)keeps daily record of care.
While researching Facilities, I was told on five documented phone calls that Assisted Living was fine , as long as it met the certificate
Definition.( of nursing home) Now, that my father is moved in to his facility, they will not approve the facility, reason
" They have changed their mind"
Now they state they only cover skilled nursing, although never mentioned in contract. They are aggressive and deceptive on the phone.
I have reported this to The State of Indiana Insurance Department, and Attorney General !
Any advice for action steps?

 

[VolAgent]

Do you still have the policy? Policy definitions rule. They may do more than what is required by the policy, but that is only at their discretion. To do less than what the policy requires leaves them open to a lawsuit and accusations of bad faith in handling claims.

Does an assisted living facility meet the definition of 24/7 nursing care under the supervision of an MD? If not, did they put in writing that assisted living is ok?

 

[Mr_Ed]

My experience with Allstate Long Term Care has. Been a nightmare! My father purchased a LTC in 1991.
The policy states that it covers nursing home care,
Nursing home defined as:
1) licensed 2) 24/7 nursing care under supervision of MD. 3)keeps daily record of care.
While researching Facilities, I was told on five documented phone calls that Assisted Living was fine , as long as it met the certificate
Definition.( of nursing home) Now, that my father is moved in to his facility, they will not approve the facility, reason
" They have changed their mind"
Now they state they only cover skilled nursing, although never mentioned in contract. They are aggressive and deceptive on the phone.
I have reported this to The State of Indiana Insurance Department, and Attorney General !
Any advice for action steps?

You should have received a letter explaining the reasons for the decline. Have you received that letter?

 

[Badandy1]

Do you still have the policy? Policy definitions rule. They may do more than what is required by the policy, but that is only at their discretion. To do less than what the policy requires leaves them open to a lawsuit and accusations of bad faith in handling claims.

Does an assisted living facility meet the definition of 24/7 nursing care under the supervision of an MD? If not, did they put in writing that assisted living is ok?

Thank you! I have the contract.
The Assisted Living Facility meets all criteria of his contract. They did not authorize this ALF in writing but via phone. They did approve a different facility we looked at, written. I mentioned I would move him there , and was told they will recind that approval.
They continue to say they have changed their mind on how they implement claims.
I have contacted a lawyer.

 

[Mr_Ed]

Thank you! I have the contract.
The Assisted Living Facility meets all criteria of his contract. They did not authorize this ALF in writing but via phone. They did approve a different facility we looked at, written. I mentioned I would move him there , and was told they will recind that approval.
They continue to say they have changed their mind on how they implement claims.
I have contacted a lawyer.

did you get a letter from them explaining why the claim was denied?

 

[Badandy1]

You should have received a letter explaining the reasons for the decline. Have you received that letter?

No letter yet. I called to follow up and was told , they changed their mind and no longer would approve Assisted Living , even if meets contract language criteria.
I just don't think they can do that. It makes sense they must follow contract, right.
The contract states : must be licensed.
Does not say anything about what license.
The claims adjusters always add, they meant , Skilled Nursing, although not specified in the contract.

 

[Mr_Ed]

No letter yet. I called to follow up and was told , they changed their mind and no longer would approve Assisted Living , even if meets contract language criteria.
I just don't think they can do that. It makes sense they must follow contract, right.
The contract states : must be licensed.
Does not say anything about what license.
The claims adjusters always add, they meant , Skilled Nursing, although not specified in the contract.

Can you take a picture of that page of the policy that defines nursing home and can you upload it or post it here somehow?

 

[LGilmore]

To the op make sure they are working from the same contract as you are. A lot of times policies change into new series and the person on the other end of the phone may be reading from the wrong policy series.

Happened to me a couple years ago. Had to have them pull my very old policy language up and read it back to me. Turns out during that time from purchase till inquiry they had changed definitions. The thing is, they can't change definitions on old policies, just new ones. So make sure you and them are on the same page of the same contract.

 

[Badandy1]

Thanks everyone for the replies. We are working on the same contract. Although, currently I am being told to Call Mutual Of Omaha for Assistant. I am getting confused.
Here is the actual wording of the contract we are interpreting "differently". Allstate tells me that they "used " to pay Assisted Living, but have now changed their minds. Coincidentally, they changed their minds when they recieved my Fathers claim.


This policy covers Nursing Home:
Nursing Home means a facility which 1)is licensed by the state in which the facility is located to provide care for sick and injured persons at their expense, 2)provides 24 hour care by or under the supervision of a Doctor , RN, LPN or LVN and 3) maintains medical records for each patient.

A nursing home does not include. 1)a hospital except for a portion of a hospital specifically designated for use as a Nursing Home, 2) a place that is primarily for the treatment of mental illness, drug addiction or alcoholism or 3)a place owned or operated by the Insured Person or a member of the Insured Person's Family.

Allstate now states that Nursing Home actually means Skilled Nursing HOme that is approved by Medicare, nothing else. Not how I read that contract.

Thanks for any insight!!

 

[VolAgent]

I will assume you copied everything verbatim.

First, is there anywhere else in the policy that Nursing Home is defined? Is there a reference to Skilled Nursing Facility or Medicare approved anywhere in the policy?

Second, does the facility you want to use meet the definition you listed? Particularly points 2 and 3.