Researchers say they could find few examples of private long term care (LTC) insurers wrongly denying claims.
The researchers, at LifePlans Inc., Waltham, Mass., a unit of Munich American Reassurance Company, Atlanta, have reported that finding in an LTC insurance claim determination review that was delivered in April and commissioned by the U.S. Department of Health and Human Services (HHS).
HHS posted the report Friday on the website of the HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE).
An audit team of registered nurses from LifePlans examined about 1,200 claims submitted in 2007 and 2008 to 7 LTC insurers–Bankers Life and Casualty Company, Chicago, a unit of CNO Financial Group Inc., Carmel, Ind. (NYSE:CNO); a unit of Genworth Financial Inc., Richmond, Va. (NYSE:GNW); John Hancock Life Insurance Company, Boston, a unit of Manulife Financial Corp., Toronto (NYSE:MFC); Long Term Care Partners L.L.C., Portsmouth, N.H., which runs the group LTC insurance program for Federal employees; MedAmerica Insurance Company, Rochester, N.Y.; a unit of MetLife Inc., New York (NYSE:MET); and a unit of Prudential Financial Inc., Newark, N.J. (NYSE:PRU).
LTC insurers approve the vast majority of claims submitted, but the
claim auditors looked at a large number of denied claims to improve the credibility of their data.
The auditors concluded that they would have denied roughly the same proportion of claims as the carriers did, LifePlans researchers say.
The auditors concluded that they would have approved 5% fewer cases than the insurance carriers approved.
In 5% of the cases, the auditors found that they could not come to a conclusion with the information on hand as to whether a claim was wrongly approved or disapproved.
The potential maximum liability for all initially approved decisions by the insurance companies totaled about $156 million, researchers estimate.
The total potential liability for all denied claims was $60 million, and the liability for the claims the auditors would have approved was about $720,000, the researchers say.