The most common mistakes that should not be made when filing a nursing claim

The insurance companies report many long-term care insurance claims that are submitted to them, due to common mistakes made by the claimants.

Acknowledge the common mistakes

Alon Hassid, in collaboration with zap doctors

24/10/2021

Sunday, 24 October 2021, 16:33 Updated: Monday, 20 December 2021, 07:26

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Nursing (Photo: ShutterStock)

Statistics show that almost half of the insured in the State of Israel who file a nursing claim are rejected outright by the insurance companies.

This means that large sections of the Israeli public who rely on long-term care insurance to help them if they deteriorate into a long-term care situation, find themselves without the desired financial compensation, precisely when they need it most.

We asked the experts of Magen, which accompanies the insured of the health funds and insurance companies in realizing their long-term care benefits, what is important to emphasize when filing a long-term care claim in a way that will increase their chances of winning the claim.

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In collaboration with zap doctors

Incorrect assessment regarding the treatments provided by the HMO

Many HMO insureds in long-term care insurance policies are unaware of their long-term care rights and believe that the medical-nursing care provided to them at home by the HMO nurse is the long-term care they receive from the insurance policy they pay for each month.

The reason for the misunderstanding stems from the process of purchasing the insurance made through a representative of the HMO and not directly through the insurance company.

The solution: Know your rights - When you purchase long-term care insurance through the HMO, you must know that the HMO serves as a "pipeline" for transferring funds and the long-term care claim will be made directly with the insurance company.

The medical treatment you receive at your home by a nurse or a doctor on behalf of the HMO is given to you due to your membership in the HMO and not due to the purchase of long-term care insurance through the HMO.

A statement of claim expressing hypersensitivity

Many lawsuits are filed by the children of the insured who are witnessing a rapid deterioration in the medical condition of their parents and are anxious for peace.

This situation leads to the filing of a lawsuit which is characterized by a very emotional tone that describes the loneliness and the feeling of misery and misery experienced by the nursing parent.

Although this testimony describes the sad reality, it does not help to confirm the claim, since the insurance company focuses on the conditions that qualify for the benefit and not on the mental state of the insured.

The solution: When filing an independent nursing claim it is important to first delve into the insurance policy, understand the various subtleties and assess what may affect the chances of winning the claim.

Focusing on a particular medical problem

Another characteristic that is prevalent when filing a nursing claim independently deals with the declaration of very distinct medical problems and the lack of important and significant information from the insurance company.

This phenomenon is prevalent when there is trauma or injury that obscures other medical problems that can contribute to and overwhelm the medical portfolio like severe lung disease or comorbidities.

The insured are unaware of this and omit statements about other serious medical problems and thus miss the real cause of nursing.

The solution: Before filling out the nursing claim, consult with those who are knowledgeable in the field of filing nursing claims who will be able to delve into the insurance policy for you and guide you through the process.

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Misunderstanding the language of insurance

The long-term care claim form refers to the day-to-day functioning of the insured.

In most cases the insured will be asked to describe whether he can perform certain actions and what is the level of independence he can do so.

In many cases it is customary to use the phrase "it is difficult for me" - "it is difficult for me to shower", "it is difficult for me to dress on my own" and so on.

When the insurance company reads that the insured has difficulty performing a certain action, she can conclude that he may not need close nursing assistance because he manages to eat alone, shower or dress on his own - even if he experiences difficulties - as a result the insurance companies report the claim.

The solution: You need to include many descriptions that help the insurance company assess that the person is nursing and needs daily help in performing operations.

For example: you can replace the phrase "difficult for me" with the phrase "can not".

Donate information to the insurance company

Many are unaware of the fact that road accidents are excluded from insurance policies and yet state this in the claim form.

For example, suppose a person had a car accident about a decade ago and as a result of the accident he was injured but continued to function and over time he experienced another medical deterioration that was not related to the accident but led to a nursing condition.

If he has declared a car accident then chances are the insurance company will dismiss the claim automatically.

The solution: be well acquainted with the conditions and in particular the exceptions in the policy and avoid as much as possible the sharing of information that may lead to the failure of the process.

Use of inaccurate medical terms

Acceptable and accurate medical diagnoses that help promote long-term care insurance are often replaced by certain terms that describe the condition but do not meet the ADL test criteria (test for assessing the level of function). For example: . The reasons for making a mistake in the diagnosis are due to the fact that most of the time the patient turns to the family doctor and not to a professional doctor - where the family doctor will describe the condition as frequent urination while a urologist will describe the same situation as incontinence.

The solution: Before filling out the claim form, examine what is the appropriate medical diagnosis that will help you increase the chance of the claim being approved. If you are not proficient in the field, you can seek the help of professionals who will guide you in the matter.

In conclusion, in constructing the medical file it is important to focus on the medical history of the insured that allows him to receive retroactive eligibility.

It is important to take care of hundreds of supportive medical diagnoses and focus the claim on these diagnoses and not on the patient's mental state.

Magen Expertim, which accompanies long-term care insurance policyholders in exercising their rights, has gained extensive experience in the field and has developed a method that allows the insurance company to present the information in an orderly manner in order to expedite treatment with the insurance company and increase the chances of approval.

For details on the escort process and to check eligibility (free) to receive the money from the long-term care insurance - please fill in details in the following form:

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or call the expert shield: 072-3932911

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