TriPlus Services

May 16, 2018Dear ***,

Thank you for your letter regarding the above-referenced policyholder. We are taking this opportunity to address your correspondence of May 2, 2018 regarding ***’ policy, which was received in our of?ce on May 7, 2018.

A review of ***’ file indicates she called on May 19, 2017 to initiate a home health care claim. While discussing caregivers, *** indicated her daughter, ***, would be providing care. An information packet was sent to *** on May 22, 2017. The packet included information and forms to be completed in order for *** to receive benefits for care provided by ***. Specifically, the packet included a Family Member Caregiver (FMCG) Pre-approval form for *** to complete as well as Home Health Care Documentation (HHCD) forms. An Attending Physician's Statement (APS) was also faxed to the policyholders physician on the following date. We did not receive the completed forms and follow-up requests were sent for the required claim information on June 5, 2017, June 15, 2017, and June 29, 2017. Because this information was not received, the claims examiner discontinued active processing of ***’ claim on July 14, 2017.

In January 2018, Penn Treaty received the APS form from the policyholders physician. After a review of this document and the results of an in-home assessment that was completed by an independent vendor, *** was determined to be eligible for benefits under her policy.

Please note that ***‘ policy is a reimbursement policy and benefits are only payable when there is a charge incurred for eligible services that she is legally responsible to pay. Her policy confirms this under the "HOMEMAKER CARE BENEFITS" section on page four (4) which states:

“For each day You receive Homemaker Care in Your Home and meet the Homemaker CareBenefits Conditions of Eligibility, We will pay the lesser of:

1 ) 80% of the actual charge incurred: or2) 80% of the Maximum Daily Benefit listed in the Policy Schedule; or3) 80% of the reasonable and customary fee for similar services rendered in a similar facility in the same geographic area.

You can qualify to receive up to 100% of the actual charge incurred, subject to 100% of the MaximumDaily Benefit, by notifying Us that You will be receiving care/assistance prior to, or within fifteen (15) calendar days of, the care/assistance beginning. To notify Us, You must call Our Claims Department at . (Please refer to the Early Notification of Claim provision on Page 12 for more details. )” (Emphasis added.)

Please note that ***’ policy includes a “Family Member as Caregiver Benefit" listed on page sixteen (16), which states:“Homemaker Care, Personal Care and Home Health Care provided by a Family Member or someone already living at Your address prior to the inception of, or need for, the care/ assistance, is not covered by this Policy, unless the caregiver is pre-approved by Us.

To obtain pre-approval of care/assistance provided by a Family Member, other than a spouse or someone living with You prior to the inception of, or need for, the care/assistance, You simply have to call Our Claims Department at to inform Us that You need care/assistance covered by this Policy and that You would like a Family Member to provide a portion or all of the care/assistance. We will then ask for information pertaining to Your needs, the Family Member and the schedule of the care/assistance to be provided by theFamily Member.

(Spouses and individuals living with You prior to the inception of, or need for, the care/assistance will not be eligible for benefits under any circumstances.)

The FMCG form and HHCD forms were received for ***. The proof of address submitted with the form was in two different family member's names and the driver’s license submitted had expired. Proof of payment had been requested because of the reimbursement nature of the policy; however, the check copies submitted as proof of payment did not appear to be cashed. Additionally, the HH CD forms indicated that *** had provided care to *** on multiple days over a time period we had been informed that *** was sleeping. When calls were placed to obtain clari?cation regarding these discrepancies, the claims examiner was not able to reach either the policyholder or the caregiver. After a review of all information within the ?le, it was determined that there was too much con?icting information to approve *** as a FMCG and the enclosed denial letter was sent on February 9, 2018.

We received the enclosed appeal letter from ***‘ son-in-law on March 13, 2018 and the enclosed answer was sent on April 24, 2018 upholding the denial of *** due to the multiple discrepancies noted in the ?le and our inability to contact ***. Please note that while *** has not been approved as a FMCG under the policy, *** has been determined to be eligible for bene?ts under her policy and has been noti?ed that if she were to retain an eligible caregiver, her claim will be reopened for processing.

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: ***.

Sincerely,

Brandice M.Lead, Customer Dispute Resolution