Note: To make this piece amusing, I have taken out most of the facts. The real story is much longer and, frankly, horribly tedious. It is after all about insurance policies, fraudulent insurance policies. — cbm
Profitable Misnomers, Fraudulent Insurance Policies
While it is true that my father never read the policy, it is also true that he was hoodwinked. He signed on to a policy called long-term care insurance and paid into it for 30 years, expecting at some point to get long-term care coverage. But let’s put knucklehead gullibility aside for the moment and consider how the policy was introduced to him.
It was a typically hectic, senseless white-collar workday. As my father pushed paper under pressure, here came another item, a circular. He didn’t have much time for it. Once you’re retired, as he has been for 30 years, it’s hard to recall what all the fuss was about, and my father does not remember why the pressure was on that particular day, but it was, and it was painful, as every day.
Offices are jungles in cages; your predators know where your desk is and know you’re supposed to be at it most of the time, one reason teleworking is so attractive. My father, industrious, conscientious, and rather courageous to be both, sat vulnerable and exposed at his desk on that particular day when the predator, taking the unlikely form of that circular, pounced. Dad glanced at it and couldn’t help noticing the title of the policy it introduced, long-term care, then couldn’t help thinking that’s what it was. It sounded sensible, prudent. Sponsored by his employer, no less, Bell Atlantic Corporation. Even better. It meant security, no funny business. And the circular had probably introduced the policy in positive if not messianic terms. Nothing wrong with a little extra protection. He signed up and forgot about it. Once the Basic Option was sent round for perusal however many weeks later that was, my father felt – human psychology being what it is – that he knew what was in it. He was wrong, of course.
The day finally came when, at 94, my father needed long-term care. After a bad fall, which necessitated hospitalization and rehab, he prepared with deep unwillingness to move from his large house, down one of its many staircases he had fallen, into an assisted-living home. Always careful with his finances, he drew up table after table of his anticipated monthly expenses, but he knew his numbers: $1,500 maintenance costs for the house, with tax and insurance fees averaged in; $4,350 for his one-bedroom accommodation at the assisted-living facility; $5,850 total, not quite what his pension would cover. With the $100-a-day coverage he was told he could expect from his long-term care policy, he could swing it until his son was established in the house with his family.
September 16, 2015, was moving day, a bleak day, a scary day, an expensive day. (The $500 moving costs were anticipated; the $500 move-in fee was not.) That day, as newly inducted facility resident, fees hit Dad like buckshot pinning quail confounded on newly sown soil. The rhetorical camouflage of a lifetime fell away in the first meeting with the facility’s administrator. Dad sensed he had entered the hostile territory of a virulent gaming industry; that his tender tissue was just the thing it fed on; and that his essence would soon be sucked dry if that long-term coverage didn’t kick in toot-sweet. But that was merely to beckon two-fisted Joe’s second blow, the entrance of another contestant ready to feast on my father. The strike came mid-October when my father’s long-term care insurer, Mutual of Omaha (Moo), sent Dad a letter denying him coverage. They were sorry, but anything they gave to him would deprive those who did qualify.
So. Dad’s long-term care policy did not cover long-term care. What did it cover? When I asked my father for the policy in order to find out, he scoffed. That was 30 years ago; he didn’t keep anything for that long (except a whole slew of suits, ties, and shoes, I knew). I called the insurance company. I was not my father’s power of attorney, Insurance Lady Ms. L informed me; she wasn’t permitted to talk to me about my father’s policy. I notified my brother, who was Dad’s power of attorney, to get that inchworm moving on the case at Hamlet’s pace. I contacted Ms. H, the woman at Dad’s assisted-living facility who handled paperwork involving residents’ long-term care insurance policies. Ophelia-like, she self-defused. Truth struck: The world worked for Moo.
After much work and little help, I finally got my hands on a copy of Dad’s “Group Long Term Care Benefits, Basic Option.” To determine his coverage all I had to do was read through its 64 pages of definitions, general provisions, exclusions, preexisting conditions, general exclusions and limitations, and modest finale of five additional definitions tucked at the back, having been forgotten when the initial Definitions section was written and left there to avoid having to repaginate the document. If you can think of another reason for leaving them there instead of inserting them where they clearly belonged, I would like to know it.
My sense of success was short-lived. I did not have the whole thing, not by a long shot. Scattered throughout the Basic Option were urgent warnings that I had to read the Master Policy, the Riders, the Certificate Validation Form, Dad’s original health application, and the Policyholder’s application in order to understand the full coverage the insured person was entitled to. I had none of those documents. I did know by this time that the policyholder was Verizon Communications, who had taken over from Bell Atlantic Corporation some time ago in the deep troubled corporate past.
Getting those missing documents turned out to be a problem. Although asked many times in many ways (telephone, email, certified mail) by many people – including Hamlet and Ophelia, Ms. L alternately said they were still looking, a method that did not seem to work for them, and we’ll send them, which they also hadn’t mastered; we never received anything. With time to submit an appeal running out, I panicked and brought to Ms. L’s attention that my father could file suit against them in Federal court if they did not send documents he requested relating to their decision to deny him coverage within 30 days of the request, pointing out that the Basic Option said so under its “Statement of ERISA Rights.” I experienced the wonder of same-day response: Ms. L said Verizon Communications had all those documents. After 30 days of putting us off. And gave us the phone number.
Just at this time, my strategy for an appeal began to gel. I had been reading up on the subject and studying the document I did have, Dad’s Basic Option. The denial letter helped me, too, by naming the single point on which Dad’s coverage was denied: Moo maintained his assisted-living facility did not provide 24-7 nursing care. This puzzled me. Round-the-clock nursing service isn’t mentioned in the Basic Option.
Services covered include skilled, intermediate, and custodial nursing care the insured person is to receive while confined as a resident patient in a nursing care facility. The policy then defines a nursing care facility as a facility that: is licensed or certified by the state in which it is located to provide skilled, intermediate, or custodial care as its main function; provides continuous room and board for at least three people; and is supervised by an on-duty RN or LPN. Once again, no mention of 24-7 nursing service. I had to assume it appeared in the state licensing requirements for nursing facilities and looked there, but found the state code is based on the federal code, so I looked there as well. “Nursing Services” are treated in detail in both.
Once I got to the spot, I found that federal regulations listed multiple alternatives to providing 24-7 nursing services and supervision, in essence, stating that it isn’t necessary. The state code starts off much in the spirit of the federal code, to wit: “The facility shall provide services by sufficient numbers of personnel on a 24-hour basis to provide nursing care to meet the needs of all residents.” This my father’s facility fulfills without question. However, the state regulations put the starch back into the staffing requirements. In place of the federal waivers softening the rule for round-the-clock LPN presence, the state code stipulates that at least an LPN must be on night shift with an RN on call within a 30-minute drive of the facility. Yet it is the use of the word “sufficient” mentioned in both state and federal codes that I consider the pivotal requirement. It is on that basis I am drawing up Dad’s appeal.
My father is not in a position to take care of himself. That is why he moved into an assisted-living facility. Should an “episode” occur to someone at 94, it is natural to assume the outcome could be grim if requisite nursing care were not hailed and dispensed in short order. Of this, my father’s facility is fully aware. They assess the needs of residents prior to admission in order to ensure that the facility is equipped with the skilled personnel and services those residents will require whenever they are needed and at emergency pace. To support this anytime, immediate care policy, residents are required to wear medical alert devices around their necks at all times.
To check this, I emailed the facility administrator, asking what care my father would receive should he have an attack in the middle of the night, i.e., during the mandatory night shift of Moo’s policy that was cited as lacking at my father’s facility. I was immediately assured that the facility had all the staff, skill, and equipment my father would require within minutes no matter when an attack should occur. She offered to hold a conference call to discuss this with me in detail. For me, the point was clear.
Just as the shrewd hippo keeps cool submerged in his mangrove swamp sultry nights, lifting merely its sly eyes above the surface to keep watch over his crew snoozing midst unruly jungle growth, so it is with my father’s facility; it need not strut expensive staff through halls nights pushing unwieldy carts and IV units when it knows from expert evaluation that its residents are unlikely to need heavy guns while they sleep; yet, those guns, the cavalcades, the cannon and shot can be rolled out at a moment’s notice – yes, 24-7 – if and when the need arises. That, for me, is 24-7 nursing care applied in just the measure to fulfill the needs of its residents, which is in fact the first requirement of both state and federal codes. Not incidentally, this judicious just-as-needed dispensation keeps the care as economical as possible as well, a growing concern for us all, Moo, too.
I do not expect to win the appeal. I expect Moo to point out to me very early on that loaded first sentence of the Basic Option’s brief section “Authority to Interpret Policy,” to wit: “By purchasing this Policy, the Policyholder grants us the discretion and the final authority to construe and interpret the Policy.” Now, anyone who has read through the Definitions section of the Basic Option will know that “Us” means Them, and Them is Moo. What I have to say or think about the matter is irrelevant. Their construe, I have no doubt, will have my father wheeled out into the shabby corridor of his nightmares to be served by the truly dedicated, the buffeting drafts.
 The word “nursing” is missing here in the policy’s text.
 Code of Federal Regulations Title 42: “Public Health”; Chapter IV: “Centers For Medicare & Medicaid Services, Department of Health and Human Services”; Subchapter G: “Standards and Certifications”; Part 483: “Requirements for States and Long Term Care Facilities”; Subpart B: “Requirements for Long Term Care Facilities”; Section 483.30: “Nursing Services.” Which is why few laymen read these things.
 They are enshrined in Pennsylvania Code Title 28: “Health and Safety”; Section 211: “Program Standards for Long-Term Care Nursing Facilities”; Subsection 12: “Nursing services.”
 Pennsylvania Code Title 28; Section 201: “Applicability, Definitions, Ownership and General Operation of Long-Term Care Nursing Facilities,” “Requirements” notes that Pennsylvania Code diverges from Federal Code Section 483.30 on items b, c, and d.