Denial by MetLife on a long term care policy

A relative is in a memory care unit in West Palm Beach, Fl. We were told by the physician on staff, and an independent doctor that she has severe cognitive issues and can not live on her own or in their assisted living section. We then considered moving her back to her home and had her evaluated for a nursing service to come for part of each day. Because she is currently in a locked memory care unit she was given a BIMS Brief Interview of Mental Status. The score range is from 1-15. She scored a 4 with 0-7 being severe impairment. We were told she would need 24/7 care.
She was interviewed by an independent doctor sent by MetLife who said it is not severe enough. MetLife has refused to pay on her long term care policy.
Do we have a case to appeal?

Asked on January 11, 2019 under Insurance Law, Florida

Answers:

SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 2 years ago | Contributor

For an internal (within the agency) appeal, you would try to show them that under the terms of the policy, which is a contract (and so whose terms on binding on them) they should pay out. In addition to the doctor's report and testimony, having an expert from the insurance side of things, who can testify that in his/her experience, your relative is sufficiently impaired so that the long care policy should be paid, would be helpful; or having someone from the nursing, etc. home industry (e.g. a consultant or advocate or social worker from that industry) who can show that people with your relative's degree of impairment do have their long-term care policies paid, would also be very helpful. You need a knowledgeable person who can provide documentation and testify that given the terms of this policy and your relative's medical condition, it is customary and appropriate to pay out on a long-term care policy. The person testifying must have education, training, and/or industruy experience qualifying him or her to render an informed, reliable opinion.
For an external "appeal" (e.g. suing the insurer for breaching or violating its contractual obligations under the policy) you would need the same evidence.


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