As we know, Parkinson's disease is a progressive disease, which affects the patient's functional status significantly, especially in its advanced stages. In cases where the functional impairment is severe and the patient has difficulty performing basic daily activities, many patients turn to look for sources of assistance - and usually come across nursing insurance. Many of us have heard the term "long-term care insurance" at least once in our lives. This term, which can be foreign and irrelevant for many people, takes on a lot of importance for Parkinson's patients, and is often the subject of many discussions and debates, most likely due to dealing with the various insurance companies.
Many policyholders pay large sums to the various insurance companies every month for long-term care insurance coverage, hoping that if God forbid they become long-term residents and need the insurance benefits - the insurance company will stand by them. Unsurprisingly it must be said, nursing claims Many that are submitted to the insurance companies are rejected arbitrarily and disconnected from reality, while causing a grave injustice to the insured. In this review, I will explain what long-term care insurance is, how the rights are exercised, what the insurance companies' common reasons for rejection are, and what to do when the insurance company decides to reject the claim.
Nursing insurance - what is it?
Long-term care insurance is in fact a contract concluded between an insurance company and the insured, according to which it is agreed that in the event that the "insurance case" occurs and the insured becomes nursing in accordance with the terms of the policy, the insurance company must pay fixed monthly rewards, in one of two ways, compensation or indemnity, during the period specified in the policy And this against monthly insurance premium payments (in the professional jargon "premium") on the part of the insured. At this stage, the question arises in which cases will the insured be entitled to monthly insurance benefits in a long-term care policy?
Well, there is a very clear answer to that. Many years ago, the insurance supervisor defined the situation in which an insured would be considered nursing, and this is also the determination in most of the nursing insurance policies that exist today. In fact, two alternatives have been determined for a nursing home situation, which are supposed to receive monthly insurance benefits: the first, the insured's inability to perform 3 out of 6 daily activities, called the ADL activities (getting up and lying down, dressing and undressing, bathing, eating and drinking, controlling braces, mobility ). It is important to note that the insured's inability to perform 50% of each action is sufficient to meet this definition. The second, the presence of a person in a state of "mental exhaustion", which is a condition that manifests itself in damage to the insured's cognitive and intellectual activity, which includes, among other things, a deficiency in insight and judgment, a decrease in short-term or long-term memory, and a lack of orientation in time and place that require supervision most hours of the day, on So that he does not pose a danger to himself and those around him. As a general rule, the reason for an insured being in this situation is Alzheimer's disease or one or another demented condition.
I am nursing - what next?
When the time comes when the insured or a member of his family realizes that he meets the "insurance case" threshold for long-term care as detailed above, he must submit the long-term care claim to the insurance company. This point is very important, since submitting the claim correctly and promptly increases the chance that the insurance company will approve the claim and pay the insurance benefits accordingly.
The claim is submitted using a structured kit that can be found on the website of the relevant insurance company, to which any document indicating the aforementioned nursing condition must be attached, including medical documentation from appropriate experts, protocols from the National Insurance Institute, and more. After the claim is filed, the insurance company has the right to examine the insured by a nursing evaluator on its behalf, in order to examine whether his condition does meet the definition of the "insurance case", in an examination called functional assessment and/or cognitive. Usually, the person who performs the examination on its behalf is a specialist in the field of geriatrics or neurology, but it is possible that in some cases the insurance company will send a social worker, brother or sister. In accordance with the above evaluation findings, the insurance company decides whether to approve or reject the claim. Unfortunately, the statistics show that quite a few nursing claims are rejected at this point, for one reason or another.
Common reasons for rejection by insurance companies in nursing claims
- The "insurance case" does not exist: As mentioned, there are two alternatives for the existence of an insurance case for a nursing situation. The insurance company that uses this reasoning actually claims that the insured is able to perform at least 3 out of 6 daily activities and that he does not meet the definition of "mental exhaustion". This is the most common and common reasoning, so it is very important not to get excited by it, but to pay attention to the basis on which the insurance company makes this claim. The source of this may be in the examination of the nursing evaluator on her behalf who determined that the insurance case does not exist, or rather as a result of the findings of an undercover investigation conducted by the insurance company. One way or another, this is nothing more than a medical dispute between the insured and the insurance company, and therefore, before taking any further action, it is recommended to consult a specialist doctor and, if necessary, contact an attorney dealing in the field who will be able to examine the rights of the insured in accordance with the terms of the policy and decide how to proceed.
- Breach of the duty of disclosure: More than once, policyholders encounter a refusal by the insurance company to pay the benefits, on the grounds that the policyholder violated the duty of disclosure when joining the policy, in accordance with Section 6 of the Insurance Contract Law. That is, the insurance company claims that at the time the insured signed the health declaration, the insured declared a different health and/or functional state than he actually had, in a way that would have affected his acceptance for insurance. Accordingly, the insurance company makes use of Sections 7-8 of the Insurance Contract Law and claims that it is exempt from paying the insurance benefits, either partially or fully, since if the insured had complied with the disclosure obligation, the insurance company would have accepted him for insurance under other conditions or not accepted him rule. It is important that the burden of proving that the insured violated the duty of disclosure established by law rests on the insurance company, and this is not at all simple. I will point out that in many cases, it is precisely the insurance company that commits a series of violations when adding insureds to the nursing policy, starting with poor supervision of the insured's joining the policy, through the sending of comprehensive questionnaires from which nothing can be learned about the health status of the insured, and ending with a violation of the obligation to inform and certify in relation for conditions and exceptions in the policy. All of these should weaken the claims of the insurance company regarding the violation of the duty of disclosure on the part of the insured. From this, it is clear that due to the conduct of the various insurance companies, which sometimes use improper means in order to reject the claims that come their way, it is recommended to contact an attorney who deals in the field, and is familiar with the methods of the insurance companies, in order to examine the matter and formulate a decision on how to deal with the company's determinations the insurance
- The existence of an exception in the policy: In every policy there are many exceptions which in certain circumstances exempt the insurance company from paying the insurance benefits. The power differences between the insurance companies and the insured are enormous and are sub-validated in the insurance contract, which is formulated exclusively by the insurance company and cannot be changed by the insured. Due to these discrepancies, when the insurance company claims to be exempt from paying the monthly insurance benefits due to a certain exception or proviso in the policy, this is not the end of the story, and there are many ways to deal with this, especially when the courts are aware of the matter. It is important to understand that, according to the ruling of the Supreme Court, while the burden of proof regarding the existence of the insurance case rests on the insured, the burden of proving that the exception exists rests on the insurance company. In the event that the insurance company makes use of this reasoning, it is recommended to contact a lawyer who practices law insurance and is familiar with the various policies, in order to examine the way in which the insurance company implemented the exception and whether it met the burden imposed on it, whether the exception was explained to the insured before he joined the insurance, and whether the exception may be considered a disadvantageous condition in a uniform contract that must be canceled.
- The insurance case occurred before joining the policy: Another reasoning that the insurance companies usually use is a reasoning that exempts them from paying insurance benefits, through Section 16 of the Insurance Contract Law, on the grounds that the insured became nursing even before joining the policy. In this case, the insurance contract for risk coverage when the insurance contract was concluded has already expired, is irrelevant and void. The logic behind this claim is to prevent the insured from joining an insurance policy knowing that the insurance case already exists and claiming the insurance benefits immediately. To the extent that the insurance company uses this reasoning to reject the long-term care claim, it is recommended to consult with an attorney knowledgeable in the field in order to properly examine whether the insured was indeed in a long-term care situation as the term is defined in the policy, on the eve of joining the insurance.
I received a rejection letter - what do I do?
As mentioned above, the insurance companies have many means of rejecting insurance claims, means which are used extensively and in a variety of ways. Therefore, if you received a rejection letter, there is no need to get excited and you should act in the following way. First, insist on receiving a rejection letter from the insurance company. According to the ruling of the Supreme Court and the circulars of the insurance inspector, the insurance company must justify all its claims within the rejection letter, otherwise, it will not be able to claim other claims, that is, additional reasons for rejection, later on. Second, do not want to file an appeal. This is a mistake A common practice of many insureds, who submit an appeal immediately after receiving the rejection letter without understanding the meaning of this. Since the front of the insurance company's claims is limited to the rejection letter only, after submitting an appeal the insurance company has the option of asserting additional reasons for rejection and actually making an "improvement allocation" which can reduce the chances of a lawsuit if the insured decides to file a lawsuit in court. Thirdly, it is advisable to collect all the relevant medical records of an insured starting from 3 to 5 years before the date of the rejection letter, and contact with them an attorney dealing in the field for the purpose of examining the chances of the case and formulating a legal strategy suitable
From the above, it is clear that the interests of the insurance company and the insured are completely different. When these interests collide, it is usually the insurance companies that come out with the upper hand. Therefore, never take the insurance company's position for granted. Contact an attorney who deals with insurance law who will be able to help you exercise your rights in accordance with the policy and the law.
