Penn Treaty

Review: I filed a claim with this insurance company at the end of May 2013 stating that I was the caregiver for my terminally ill, dying from gastric cancer, father. My claim was denied because even though he had paid his premiums on time for 15 years, because he could do 4 out of the 10 determining factors on their list then he didn't need help. I filed another claim the end of June 2013, I believe on 6/22/2013. My father passed away on 6/30/2013. The "intake" nurse, called on July 1st to come and assess the situation, 9 days after we filed the claim again. They were too late, he had passed. I have given them all the information they needed - faxed EVERYTHING to them on 7/3/2013. They claimed they didn't have everything so I had to refax them information and they got it on the 31st of July. However, they have since informed me that they approved payment on July 25th........6 days prior to me refaxing information. Today is August 7th, and I still have not received payment. I cannot close my dads affairs until this matter is taken care of. All other insurance policies have already paid out and those accounts are closed. It was hard enough taking care of my dad, and its not about the money - its about the fact that my dad paid them for so long and would have been cancelled in a heartbeat if he would have dragged his feet making a payment to them. What they owe me is NOT EVEN a drop in the bucket to what I went through, emotionally and mentally.Desired Settlement: I want a written apology and I would like for them to offer some sort of compensation toward my moms account with them since she still has a policy through them. I can only imagine the teeth that will be pulled when I need some retribution on her behalf.

Business

Response:

August 22, 2013 Revdex.com

Of Metropolitan Washington DC and Eastern Pennsylvania

50 West North St Bethlehem, PA 18018-5789

Attn: [redacted]

Re: Policyholder: [redacted]

Policy No.: [redacted]

Your ID No.: [redacted]

Dear **. [redacted]:

Thank you for your letter regarding the above-referenced policyholder. We are taking this opportunity to address your correspondence of August 9,2013 regarding **. [redacted]'s policy.

We would like to respond to the comments of **. [redacted] expressing concern with the denial of **. [redacted]'s initial claim as well as delays with the claim for her services.

Our records indicate we received notification of **. [redacted]'s need for home care under his policy on June 3,2013. When our Intake clerk spoke with [redacted], she confirmed that **. [redacted] was independent with his Activities of Daily Living {ADLs) as defined by the policy. Due to **. [redacted]'s independence with his Activities of Daily Living, he did not qualify for benefits at the time of that phone call. Please note that **. [redacted] has a Tax-Qualified policy. We have enclosed pages six (6) and seven (7) of his policy which lists his "CONDITIONS OF ELIGIBILTY":

"You will become eligible to receive the benefits available under Section I of this Policy if the care/services are received while this Policy is in force and are provided pursuant to a Plan of Care developed by a Licensed Health Care Practitioner.

Plan of Care is a written plan of Qualified Long-Term Care Services prepared by a Licensed Health Care Practitioner which: (a) specifies the type of such services that are necessary; and fb) certifies that You are a Chronically III Individual. Certification of Your condition may be required periodically, but not more than once every thirty-one (31) days.

Qualified Long-Term Care Services include any necessary diagnostic, preventive, therapeutic, curing, treating; mitigating or rehabilitative services, and maintenance services, which (a) are required by a Chronically III Individual; and (b) provided pursuant to a Plan of Care prescribed by a Licensed Health Care Practitioner.

A Chronically III Individual is an individual who has been certified by a Licensed Health Care Practitioner.

at any time in the preceding twelve (12) month period, as:

(1) being unable to perform, without Substantial Assistance, at least two (2) Activities of Daily Living for a period of at least ninety (90) days due to the loss of functional capacity: or. having a similar level of disability as determined by the Secretary of the Treasury in consultation with the Secretary of Health and Human Services.

Substantial Assistance may be Hands-on Assistance and/or Standby Assistance.

Hands-on Assistance is the physical assistance of another person without which You would be unable to perform the Activity of Daily Living.

Standby Assistance is the presence of another person within arm's reach of you thgt Is necessgryto prevent, by physical intervention, injury to You while You are performing an Activity of Daily Living.

Activities of Daily Living are the basic human functionol abilities required for You to remoin independent. They ore as follows:

1.) Eating means feeding oneself by getting food into the body from o receptacle (such as a plate, cup or table) or by a feeding tube or intravenously.

2.) Bathing means washing oneself by sponge bath: or in either tub or shower, including getting into or out of the tub or shower.

3.) **essing means putting on and taking off all items of clothing and any necessary braces, fasteners or artificial limbs.

4.) Transferring means moving into or out of a bed, chair or wheelchair.

5.) Toileting megns getting to and from the toilet, getting on gnd off the toilet, and performing associated personal hygiene.

6.) Continence means the ability to maintain control of bowel and bladder function: or, when unable to maintain control of bowel and/or bladder function, the ability to perform associated personal hygiene (including caring for catheter or colostomy bag).

OR

(2) requiring Supervision to protect such individual from threats to health and safety due to Severe Cognitive Impairment.

Severe Cognitive Impairment is confusion ond/or disorientotion resulting from g deterioration or loss of intellectual capacity that is not related to, or a result of, mental illness, but which can result from Alzheimer's Disease and other forms of Organic Brain Syndrome. Severe Cognitive Impairment must result in Your requiring supervision to maintain Your safety and/or the safety of others. The deterioration or loss of intellectual capacity is established through the use of standardized tests that reliably megsure impairment in the following areas:

1.) Short-term or long-term memory;

2.) Orientation as to person, place and time;

3.) Deductive or Abstract Regsoning." Emphasis added.

On June 21, 2013, we received correspondence from **. [redacted]'s physician confirming he had been enrolled into the Hospice Care Program and required 24 hour care, which was provided by his daughter, [redacted]. Our Intake Clerk contacted **. [redacted] on June 25, 2013 and confirmed that after a hospitalization from June 18, 2013 to June 22, 2013, **. [redacted] required assistance with all of his ADLs.

On June 25, 2013 we sent a claims acknowledgement letter to **. [redacted] with a "Things to Consider" insert and a packet of claim forms that includes all information needed to file a home health care claim using a family member caregiver. On June 28, 2013 the Attending Physician's Statement and 90-day Tax-Qualified Certification was sent to **. [redacted].

We received the Attending Physician's Statement on June 28, 2013 and the 90-day Tax-qualified Certification on July 16, 2013. During this period, we were notified that **. [redacted] passed away on June 30,2013.

Thereafter, on July 3,2013 the Family Member Caregiver Pre-Approval Form was received from **. [redacted]. This form includes a request for **. [redacted]'s proof of residence and photo ID, which was not received. We received this final piece of information to approve **. [redacted] as a caregiver on July 31,2013 and payment was issued on August 7,2013 to **. [redacted]'s spouse, [redacted]. A copy of this explanation of benefits is enclosed. Please note that this payment was issued within our claims department's fifteen (15) day and the policy's requirement of thirty (30) days for claim payment as noted on page twelve of **. [redacted]'s policy:

*Time of Payment of Claims: Benefits payable under the policy for any loss incurred will be paid within thirty (30) days after receipt of written proof of loss. Any balance remaining unpaid at the end of Our liability will be paid immediately upon receipt of written proof."

We trust that we have provided you with the necessary information to complete your review of this matter. Should you have any further questions or require additional information, please do not hesitate to contact me at ###-###-####, ext: [redacted].

Sincerely,

Review: My mother and stepfather have been paying premiums on a long-term care insurance policy for 15 years. They are now in need of the long-term care benefit, yet their claim has been denied by Penn Treaty and we are getting the runaround from this company. My stepfather has dementia, among other health issues. His doctor has declared that he not drive anymore and that he needs to live in an assisted living facility. The claim could not be submitted until they became residents of an assisted living facility, therefore, they moved to an assisted living facility and sold their car. It has taken thousands of dollars from my family to support them living in this environment while the claim has been pending, and months later it was denied because he is not receiving an extra tier of care which would cost an additional $575 each month. We are not able to get past the original claim rep even though the claim was handed on to her supervisors and deliberated for a long period of time. We were told that a copy of the denial would be forwarded to us, and it has not been. This situation is a horrible commentary on big business in this country. Someone at the top is making money at the expense of those who need to be provided with a service for which they have already paid.Desired Settlement: Immediate fulfillment of this claim. These are elderly citizens without great means who have paid Penn Treaty approximately 10% of their very fixed monthly income for 15 years solely for the security of knowing they would be provided with the assistance they need for a portion of their remaining years. They have been robbed of the only security they had for such a time as this.

Business

Response:

{Please see attachment.}