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LTC Mind Control

Rob Pohls
Rob Pohls

The document discusses scenarios that long term care claim handlers may encounter and how to best handle them. It explores what makes a good long term care claim handler and how to avoid errors. The scenarios involve situations like an insured seeking advice, a claim where care needs changed over time, dealing with conflicting family information, coverage questions for assistance with transportation and household tasks, and determining coverage for a couple moving into an assisted living facility. The presentation aims to identify best practices for long term care claims handling.

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Judy Bass, State Farm Mutual Automobile Insurance Company Lori Watson, Genworth Financial Watson Rob Pohls, Pohls & Associates International Claim Association 2011 Annual Education Conference Las Vegas, Nevada October 3, 2011
LTC MIND CONTROL Goals: 揃E l Explore what makes a good LTC claim h dl h t k d l i handler. 揃 Examine the unique relationship between claimant and claim h dl d l i handler. 揃 Identify approaches to avoiding pitfalls when claim handling h dli errors occur. Process: 揃 Discuss hypothetical scenarios. 揃 Questions. 際際滷 2 International Claim Association 2011 Annual Education Conference Las Vegas, Nevada October 3, 2011
LTC MIND CONTROL Scenario #1: The Advice-Seeker 揃 72 y.o. widow with Parkinsons id ith P ki and recent shoulder injury 揃 Lives alone in home; Needs help with 3 ADLs; Receives home care 6 hours/day and 7 days/week 揃 Weekly conversations with examiner, often unrelated to LTC 揃 Insured asks for advice about selecting her POA and whether to apply for Medicare 際際滷 3 International Claim Association 2011 Annual Education Conference Las Vegas, Nevada October 3, 2011
LTC MIND CONTROL Scenario #2: The New Glasses 揃 80 y.o. widow f t id fractures hi and hip d shoulder; Also diagnosed with osteoporosis, diabetes and CHF 揃 Lives alone; Receives daily home care 揃 Claim initially reviewed in detail; less attention paid once payments became routine; On claim for 3 yrs. 揃 New examiner reviews closely; Finds insured only needs help with dressing, dressing meal prep and cleaning 際際滷 4 International Claim Association 2011 Annual Education Conference Las Vegas, Nevada October 3, 2011
LTC MIND CONTROL Scenario #3: All in The Family 揃 60 y.o. f female with d l ith dementia, l ti long history of depression, narcotic and alcohol dependency, short term memory loss; family history of Alzheimers 揃 Onsite assessment reveals totally dependent in all IADLs; MMSE is 15/30; Rx = Paxil and Wellbutrin 揃 All care provided by live-in; POC calls for 24/7 oversight and ADL assistance 揃 Highly emotional claim; Conflicting information and desires from family 際際滷 5 International Claim Association 2011 Annual Education Conference Las Vegas, Nevada October 3, 2011
LTC MIND CONTROL Scenario #4: Driving Miss Daisy 揃 58 y.o. f female with b l ith breast cancer t and mets to liver; grim prognosis 揃 Insured is having difficulty with diagnosis and prognosis 揃 Onsite assessment, med records and APS show independent with ADLs and no cognitive deficits 揃 No care in place but would like assistance with IADLs, transportation to and from doctors, treatment, etc. treatment etc 際際滷 6 International Claim Association 2011 Annual Education Conference Las Vegas, Nevada October 3, 2011
No care yet in place but would like assistance with IADLs, transportation to and from doctors, treatment, etc LTC MIND CONTROL Scenario #5: The Hired Help 揃 80 y.o. f female with fi d i l ith fixed income finds premium notice after husband passes; calls with Qs re LTC policy 揃 Examiner explains eligibility criteria (insured denies CI and need for ADL assistance); Also explains nursing home only (with home care rider) 揃 6 months later, insured calls again to say she has hired a housekeeper who helps with meals, chores, transportation, etc. 際際滷 7 International Claim Association 2011 Annual Education Conference Las Vegas, Nevada October 3, 2011
LTC MIND CONTROL Scenario #6: For Better or For Worse 揃 83 y.o. f female with shoulder i j l ith h ld injury and d 85 y.o. male with cardiac problems live independently their home; When males condition deteriorates, they consider moving into an ALF 揃 Male calls to ask if an ALF would be covered by his policy; Examiner says benefits available if male is benefit eligible and ALF meets definition of NH 揃 After selling their home, couple moves into ALF; Male is covered (b/c needs ADL assistance); Female is not covered 際際滷 8 International Claim Association 2011 Annual Education Conference Las Vegas, Nevada October 3, 2011
LTC MIND CONTROL Judy Bass, State Farm Mutual Automobile Insurance Company Lori Watson, Genworth Financial Watson Rob Pohls, Pohls & Associates International Claim Association 2011 Annual Education Conference Las Vegas, Nevada October 3, 2011

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LTC Mind Control

  • 1. Judy Bass, State Farm Mutual Automobile Insurance Company Lori Watson, Genworth Financial Watson Rob Pohls, Pohls & Associates International Claim Association 2011 Annual Education Conference Las Vegas, Nevada October 3, 2011
  • 2. LTC MIND CONTROL Goals: 揃E l Explore what makes a good LTC claim h dl h t k d l i handler. 揃 Examine the unique relationship between claimant and claim h dl d l i handler. 揃 Identify approaches to avoiding pitfalls when claim handling h dli errors occur. Process: 揃 Discuss hypothetical scenarios. 揃 Questions. 際際滷 2 International Claim Association 2011 Annual Education Conference Las Vegas, Nevada October 3, 2011
  • 3. LTC MIND CONTROL Scenario #1: The Advice-Seeker 揃 72 y.o. widow with Parkinsons id ith P ki and recent shoulder injury 揃 Lives alone in home; Needs help with 3 ADLs; Receives home care 6 hours/day and 7 days/week 揃 Weekly conversations with examiner, often unrelated to LTC 揃 Insured asks for advice about selecting her POA and whether to apply for Medicare 際際滷 3 International Claim Association 2011 Annual Education Conference Las Vegas, Nevada October 3, 2011
  • 4. LTC MIND CONTROL Scenario #2: The New Glasses 揃 80 y.o. widow f t id fractures hi and hip d shoulder; Also diagnosed with osteoporosis, diabetes and CHF 揃 Lives alone; Receives daily home care 揃 Claim initially reviewed in detail; less attention paid once payments became routine; On claim for 3 yrs. 揃 New examiner reviews closely; Finds insured only needs help with dressing, dressing meal prep and cleaning 際際滷 4 International Claim Association 2011 Annual Education Conference Las Vegas, Nevada October 3, 2011
  • 5. LTC MIND CONTROL Scenario #3: All in The Family 揃 60 y.o. f female with d l ith dementia, l ti long history of depression, narcotic and alcohol dependency, short term memory loss; family history of Alzheimers 揃 Onsite assessment reveals totally dependent in all IADLs; MMSE is 15/30; Rx = Paxil and Wellbutrin 揃 All care provided by live-in; POC calls for 24/7 oversight and ADL assistance 揃 Highly emotional claim; Conflicting information and desires from family 際際滷 5 International Claim Association 2011 Annual Education Conference Las Vegas, Nevada October 3, 2011
  • 6. LTC MIND CONTROL Scenario #4: Driving Miss Daisy 揃 58 y.o. f female with b l ith breast cancer t and mets to liver; grim prognosis 揃 Insured is having difficulty with diagnosis and prognosis 揃 Onsite assessment, med records and APS show independent with ADLs and no cognitive deficits 揃 No care in place but would like assistance with IADLs, transportation to and from doctors, treatment, etc. treatment etc 際際滷 6 International Claim Association 2011 Annual Education Conference Las Vegas, Nevada October 3, 2011
  • 7. No care yet in place but would like assistance with IADLs, transportation to and from doctors, treatment, etc LTC MIND CONTROL Scenario #5: The Hired Help 揃 80 y.o. f female with fi d i l ith fixed income finds premium notice after husband passes; calls with Qs re LTC policy 揃 Examiner explains eligibility criteria (insured denies CI and need for ADL assistance); Also explains nursing home only (with home care rider) 揃 6 months later, insured calls again to say she has hired a housekeeper who helps with meals, chores, transportation, etc. 際際滷 7 International Claim Association 2011 Annual Education Conference Las Vegas, Nevada October 3, 2011
  • 8. LTC MIND CONTROL Scenario #6: For Better or For Worse 揃 83 y.o. f female with shoulder i j l ith h ld injury and d 85 y.o. male with cardiac problems live independently their home; When males condition deteriorates, they consider moving into an ALF 揃 Male calls to ask if an ALF would be covered by his policy; Examiner says benefits available if male is benefit eligible and ALF meets definition of NH 揃 After selling their home, couple moves into ALF; Male is covered (b/c needs ADL assistance); Female is not covered 際際滷 8 International Claim Association 2011 Annual Education Conference Las Vegas, Nevada October 3, 2011
  • 9. LTC MIND CONTROL Judy Bass, State Farm Mutual Automobile Insurance Company Lori Watson, Genworth Financial Watson Rob Pohls, Pohls & Associates International Claim Association 2011 Annual Education Conference Las Vegas, Nevada October 3, 2011