Bed Reservation Benefit

[DanLegend]

My Mother-in-law receives care in AL, and receives LTC benefits from Allianz. MIL was at ALF for days 1-18 last month, and Allianz paid benefit for those days.

MIL was at hospital for days 19-23, then SNF for days 24-30. Bed Reservation benefit is up to 14 days per year. I called Allianz to ask if Bed Reservation benefit should pay for days 19-30 (MIL pays same monthly invoice to ALF if she is there or not).

The Allianz rep said that Bed Reservation benefit for days 19-23 may be re-considered, because MIL was in the hospital.

The Allianz rep said that Bed Reservation benefit for days 24-30 would not be paid because of Allianz's "interpretation" of the exclusions. He went on to read me excerpts of the exclusions, and the wording was similar to "if the insured is hospitalized in a government facility, and government insurance pays benefits..."

The Allianz rep said that the "state insurance commissioners" all have approved Allianz's interpretation of the exclusion.

I have requested a complete copy of the policy, so I can get the exact wording. The total Bed Care Reservation benefit for days 24-30 would be $1029.00. On general principal it makes sense to me that Allianz should pay for these days. They would have paid if she was still at her ALF, and it wasn't like her condition improved and she no longer qualified for benefits during those days.

If it isn't hopeless, what would be the best way to go about convincing Allianz to pay benefits for Bed Reservation while the insured was in a SNF?

Thanks in advance,

DanL

 

[DanLegend]

This is the wording from my MIL's policy, from Part 4: Exclusions and Limitations, that the rep said that Allianz is interpreting to deny bed reservation benefit while my MIL was at a SNF:

"GENERAL EXCLUSIONS
This policy does not cover any loss, illness, accident, medical condition, treatment or services:
:
:
6. Provided in a government facility, (unless otherwise required by law), services for which benefits are available under a government program (except Medicaid), any state or federal workers' compensation, employer's liability or occupational disease law, or any motor vehicle no-fault law;"

So Allianz's interpretation is that, because the SNF provided treatment to my MIL paid for by Medicare, then Allianz is not required to pay benefits.

I would offer that Allianz is ignoring the fact that the SNF is not a "government facility".

I also can't figure out why the rep says that the adjuster will re-consider paying benefits for the days that my MIL was hospitalized. It seems to me that if you follow Allianz's logic for excluding benefits while the insured is in a SNF, then benefits should also be excluded while the insured is in a hospital, receiving treatment paid for by Medicare.

Is excluding Bed Reservation benefits for Hospital and/or SNF stays common with LTC policies?

Thanks in advance,

DanL

 

[Mr_Ed]

This is the wording from my MIL's policy, from Part 4: Exclusions and Limitations, that the rep said that Allianz is interpreting to deny bed reservation benefit while my MIL was at a SNF:

"GENERAL EXCLUSIONS
This policy does not cover any loss, illness, accident, medical condition, treatment or services:
:
:
6. Provided in a government facility, (unless otherwise required by law), services for which benefits are available under a government program (except Medicaid), any state or federal workers' compensation, employer's liability or occupational disease law, or any motor vehicle no-fault law;"

So Allianz's interpretation is that, because the SNF provided treatment to my MIL paid for by Medicare, then Allianz is not required to pay benefits.

I would offer that Allianz is ignoring the fact that the SNF is not a "government facility".

I also can't figure out why the rep says that the adjuster will re-consider paying benefits for the days that my MIL was hospitalized. It seems to me that if you follow Allianz's logic for excluding benefits while the insured is in a SNF, then benefits should also be excluded while the insured is in a hospital, receiving treatment paid for by Medicare.

Is excluding Bed Reservation benefits for Hospital and/or SNF stays common with LTC policies?

Thanks in advance,

DanL

Dan,
Can you please share the policy wording for the bed reservation benefit? Not snippets, the entirety of the bed reservation benefit.

 

[DanLegend]

I wasn't sure how large a file could be uploaded to a post. If the site will allow, I will upload the policy doc.

Thanks!

 

[DanLegend]

I was able to upload more policy details.

 

[Mr_Ed]

Thank you. I'll read it tomorrow and get back to you.

 

[DanLegend]

Ed, do you have any thoughts on this?

Thanks!

 

[DanLegend]

Thank you. I'll read it tomorrow and get back to you.

I'm a little surprised this has gotten over 250 views but no one has offered an opinion. I'm happy that no one has said that getting this bed reservation benefit is hopeless, so I'll push on for now.

Allianz paid my MIL's claim for the 17 days in April she was confined in her AL facility, leaving 13 days in April when she was confined to hospital and SNF unpaid (bed reservation benefit denied). There are two additional days in May when she was in SNF that likely will be denied for bed reservation benefit as well.

I will wait until the May claim has been processed and paid to avoid having to communicate with Allianz twice (once for the benefit denied in April, once for benefit denied in May). I will ask for specific information behind the reasoning for denying bed reservation that I can use to call the KS consumer insurance hotline, write letters, etc.

Any ideas would be appreciated.

Thanks!

DanL

 

[ltcadviser]

I'm a little surprised this has gotten over 250 views but no one has offered an opinion. I'm happy that no one has said that getting this bed reservation benefit is hopeless, so I'll push on for now.

Allianz paid my MIL's claim for the 17 days in April she was confined in her AL facility, leaving 13 days in April when she was confined to hospital and SNF unpaid (bed reservation benefit denied). There are two additional days in May when she was in SNF that likely will be denied for bed reservation benefit as well.

I will wait until the May claim has been processed and paid to avoid having to communicate with Allianz twice (once for the benefit denied in April, once for benefit denied in May). I will ask for specific information behind the reasoning for denying bed reservation that I can use to call the KS consumer insurance hotline, write letters, etc.

Any ideas would be appreciated.

Thanks!

DanL

Contractually, Allianz is correct. The bed reservation benefit is available when your mother-in-law is hospitalized. Once she transferred to the SNF, her hospitalization stay ended and her costs are being paid for by Medicare. There is an exclusion for duplication of governmental Medicare benefits.

Now, I will state that it would be better from a consumer relations standpoint if Allianz would apply the SNF days to the Bed Reservation benefit. I would be miffed as well.

 

[DanLegend]

If you think Allianz is paying benefits according to the contract, then that is good enough for me. I appreciate your input, you saved me some time fighting with them.

DanL