Policy defines requirements of home health agency to be a qualified provider to receive payment, which the agency I work for meets. Mom’s policy (from 25 yrs. ago) states immediate family cannot be compensated for providing care. LTC requires timesheet signed by insured and caregiver indicating all activities of daily care and related care activities. Policy states it has uniformity clause that reverts language to minimum allowances of state insured lives in, Michigan Medicare allows family members (excl spouse or reasonable parent-minor child relationship) to be paid for serving as care giver. When home health care agency submits this info with my name as caregiver, LTC comp inquired as to whether I am related to my mother (client) and when told yes, they refuse to pay agency because they say I am immediate family though I work for home health care agency. Google shows this company as one who doesn’t operate in good faith to its insureds by stringing them along trying not to pay their claims, requiring excessive paperwork and/or info in filing claims, denying claims for ridiculous reasons, etc. My mother filed a complaint with state insurance commissioner and result stated no violation found on part of LTC company, absent specific reference to several examples of fraud/violations provided of LTC comp refusal to pay benefits to insured who met conditions. Spoke to attorney but wanted to charge $5k retainer then $300 hr. to investigate issue to make sure they get $$$ since can’t apply injury damages for millions of dollars in this case. My 88-year-old mother does not have money to pay a large attorney fee like this, when 35-40 percent of her limited pension/SS goes to insurance premiums. Is there anything that can be done legally to refute this denial and make the LTC pay the home health care agency for services they provided, for my mother who was approved by them as eligible to receive home care benefits and the home health care agency was approved as a qualified agency?
A lot of LTC policies are like that. Use someone else from the agency you work for.
Something is wrong here, when a policy is activated, premiums usually stop. Is this not happening because you are trying to be her paid caregiver?
"excl spouse or reasonable parent-minor child relationship) to be paid for serving as care giver"
The first phrase I think is perfectly clear. You cannot care for your Mom if the agency wants to get paid. As said what State Medicaid does or doesn't do has nothing to do with a private policy. Medicare is not a State run thing.
Here's your answer
"My mother filed a complaint with state insurance commissioner and result stated no violation found on part of LTC company"
So for the LTC insurance to pay, you cannot be Moms caregiver. It would not be worth Moms money to go forward with this.
I am sure that the LTC company is just covering their ass(ets) I am sure many have tried to set up ways that will try to cheat the system.
(again apologies to funkygrandma)
I would not spend time or money trying to fight a big insurance company, they have far more time and money than you do.
I am sure another member will post much more legal answer.
I am concerned that your case was based on the assertion that
“Michigan Medicare allows family members … to be paid”
1) Did you mean Medicaid?
2) Allows is not the same as requires.
3) Medicare and Medicaid do not set the standards for long-term care insurance contracts.
It is kind of a big deal when government decides that certain contract terms cannot be enforced. I would expect that the insurance commissioner would be more than aware if there was such a law in your state.
(i’m not saying it’s impossible. After all, the title report on my California home shows a deed restriction that I cannot sell to anyone of a non-Caucasian race. No competent real estate professional would be unaware that this is unenforceable.)