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How do I appeal denial of long term care insurance policy based on inaccurate medical records?
Anonymous2 views3 answers
I applied for a long term care policy for myself. I was denied. I requested from the company that denied me the records that they used to review. I discovered that the records contained inaccurate information about my medical history and medications that I currently take. I want to appeal their denial because of these inaccurate records. This problem of inaccurate records came about in 2011 when my primary care doctor closed her practice on Dec. 30, 2011.. I chose another primary care doctor who I saw, as new patient, at the end of Dec. 2011, so I could be sure of having a primary care doctor in the small town I live in. This doctor was fired a month later. Now my records from that first visit list inaccurate information. What do I do to correct the inaccurate information?
An insurance company cannot be forced by law to do business with you, even if their denial is based on incorrect information. What you must do, though, is get the chart corrected and apply to another company for coverage after it is all squared away. As mentioned, the best place to start is the practice where the primary care physician whose records are erroneous was working on the date of service by that office. Although the doctor is gone, the office should have maintained your records (the insurance company obviously got them from someone), and you need to point out the errors and demand their correction. You should find some sympathy with the office, since the doctor was there for such a short time and it may be that you were not the only patient who experienced this - perhaps you will find that was the reason the doctor was terminated at the office.
I would suggest going in to the office and discussing, in person, the problem with the office manager or managing physician (not just the receptionist at the front desk). Bring along a full letter of explanation with as much detail as you can for them to include in your records. This letter should include the CORRECT info you want in the records, after explaining the full incorrect data, without being accusing of the doctor who made the bad entries. It may require a follow-up doctor visit so another member of the practice can confirm all that you protest in the chart, but understand that they cannot just accept your word for your own medical condition and need to be sure the NEW entries are accurate and complete. Good luck!
Unless applicable state law gives you some kind of appeal rights, I don't think you have any right to force an insurer to reconsider your application. However, they probably will if your agent can show that the information is incorrect. Start with the physicians that are providing the incorrect information and show them how and why to change their records, then work with a good insurance agent who knows how to get the insurance medical information changed accordingly.
Lawrence Friedman, Bridgewater, NJ. Certified as an Elder Law Attorney by the ABA approved National Elder Law Foundation, former Chair NJ State Bar Association Elder and Disabilities Law Section, Member Board of Consultors of NJSBA Real Property, Trusts & Estates Law Section, Vice Chair Special Needs Law Section of National Academy of Elder Law Attorneys, and Master of Laws (L.L.M.) in Taxation from N.Y.U. School of Law. Visit SpecialNeedsNJ.com for articles and Q&A on elder law, special needs, wills, trusts, estates, and tax and SpecialNeedsNJ.com/blog for timely updates. Information on both and SpecialNeedsNJ.com does not constitute legal advice, as it is general in nature and may not apply to your situation or be subject to important changes. No attorney client relationship exists unless set forth in written engagement terms.
Eric Jerome GoldTrusts AttorneyCalabasas, CACA licensed ·
My colleagues are correct that, generally, an insurance company cannot be forced to do business with you, regardless of the reason (there are certain exceptions). Unless you state provides for a state-mandated appeals process, your next step should be trying to get your medical records corrected and resubmitting your insurance application to either another provider or the same one with an explanation as to the modifications about your medical history.
