I've been fighting the insurance company to pay for her long term care in her assisted living facility. At long last, I think I understand the issue, or at least the reason for the delay.
My mother's insurer, Bankers Life, will pay a set amount for her long-term-care if she either (1) has deficiencies in at least two of the six "Activities of Daily Living" (ADLs - bathing, dressing, eating, transferring, toileting, continence, and something else), OR, (2) has cognitive impairment. Mom has some trouble with ADLs, or, what are called Instrumental ADLs (more minor activities that contribute to the ability to live successfully, like, ability to dial a phone), but not enough to merit a claim on her insurance policy. She does, however, have cognitive impairment, diagnosed as Dementia by her physician. In the office, he explained that it was the beginning stages of dementia. Still, a dementia diagnosis = insurance claim, in my mind.
I've been submitting this claim without success. I kept getting turned down. I submitted my form, and the assisted living facility has submitted their paperwork.
I found out, however, a couple things: (1) the assisted living facility did not have a diagnosis from the physician for Dementia. Their cognitive assessments score her as 22 out of 30, where dementia would need a score of 20 - therefore to them, she did not have dementia. Furthermore, (2) if she DID have their version of (full) dementia, she would not be able to live there at all, since she is insulin-dependent and they do not provide that level of nursing care.
Hmm. That explains the bruises on my forehead as I've beat my head on this brick wall.
I did, however, bring the latest Bankers form to the director of the facility, and showed them that they ask whether the DOCTOR diagnosed her with a cognitive impairment. I showed the director the doctor's diagnosis. So, I'm hopeful that the facility can now submit the paperwork that might allow for the insurance claim.
If only I'd known this six, eight, ten months ago. I didn't even know what to ask. It all seemed so obvious to me.
So, we now await the director submitting the papers and the response from Bankers.