My MIL has paid $975K into her John Hancock Long Term Care policy. They have denied her claim. Should I find an attorney to challenge this?

JABadger, what were the reasons for being denied?

You may, but you may also not be successful. This is one of the problems with LTC insurance. There are many problems in the fine print and no one can read 1,000 pages of fine print. Sometimes they don't cover people if they are not in a facility with a full time RN on duty. Guess what, that doesn't exist in ANY memory care. So it is a problem for certain, and your message here serves as a warning. You surely can consult an attorney. But first know what reason they are giving for non coverage, then read the policy to see if it is part of a policy that your MIL signed. Sorry to hear this. You post detaiils of WHY they refused her claim would help others be forewarned for their future. This insurance is very costly. MANY would be MUCH better off just being self insured. That million and the interest from it would have paid for MIL's care for a good long time.
Also be certain to check to see if there is any class action suit. A suit against this company with it's hoard of attorneys just waiting for you is unlikely to be won, but there may already be a class action suit against them.

I'm curious, also, as to why they denied her claim.

Where is she now? I hope she doesn't live with you, and that you are the fulltime caregiver.

My doctor filled out part of my application for long term coverage. It went thru on the first try and kicked in when the policy said it would.

Can you tell us why the claim was denied?

Gather all the statements from begining to now and tell God to help lead the way and be ready to fight .....

You should start by reading the denial paperwork and perhaps sharing the relevant portions with anyone you’d like to give you advice.

Then proceed to do the same with the contract. (Our contract was 30 pages.)

Is there any dispute that she needs help with her ADLs or has cognitive impairment? What did her application say? Her doctor? Was a family member, who is not in denial, present at her assessment? Is she trying to get payment for care by family members when that is not covered? What is the appeal process?

At 975k she would, over at least 40 years, paid $25,000 on average a year in premiums. Thats approx 2100 a month. Are you sure this is not what the policy is worth? I hope this stays set up like I typed it but the average cost I found now is below. MIL would have paid even less years ago.

Annual Premium Estimates
Male age 55 $2,220

Single Female age 55 $3,700 (women live longer)

Couple age 55 $5,025

I also found this:

"If you need long-term care, you can tap the policy benefit. If you die before needing long-term care, the policy has a life insurance benefit. If you decide you need the money for something else, you can typically receive a cash value that can be roughly equal to or less than the total premiums paid."

I think someone from John Hancock needs to explain to you and your MIL how this policy works, EXACTLY, and what she's been paying all these premiums for that add up to a staggering $975K!

My husband and I Iooked into LTC ins a few years ago. When we added it up we estimated we would have paid premiums amounting to about $350K between the both of us over the years. And then learned that they would pay out only a certain amount lasting just a few years. After that, we would be on the hook for paying for our own care again. We figured at that rate we would just set that money aside instead of pay astronomical insurance premiums. If we need the care we'll self pay. If we don't need it then we'll still have the savings account. Policies vary. You do need to know what your paying for with these policies. They don't all offer life insurance/cash value so you need to check that. Also premiums increase every year. They dont necessarily stay so low as when you are 55 years old.

My husband got our Long-Term Care ins. about 25 years ago thru his union benefits. His premiums were high but not like I've read here on AC. Since my care was caused by an accident it was easy for my doc to fill out the claim. It kicked in at 120 days and I have 8 years of coverage. I also get a food delivery allowance from my health insurance Medicare Supplement.

Thank you, everyone, for the helpful answers! I did misspeak when I said she had paid in $975K. That is actually the current value. The reason for being denied, based on an independent in-home assessment, she did not meet criteria for cognitive impairment and was deemed to not need help with any activities of daily living. In fact, she doesn’t bathe, rarely changes her clothes, doesn’t eat enough, needs someone to wheel her in to doctor’s appointments, etc. I thought John Hancock would reach out to her many doctors (for whom I gave their contact info and her diagnoses), but they didn’t contact a single one. My first step in appealing the denial is going to be asking every one of her doctors (including the ones attending her 3 inpatient hospital stays in the past 4 months) and asking for letters of recommendation.

Regarding lawsuits, there have been at least two big ones against John Hancock.

JA; They may simply have called HER and asked what her needs were.

If she said she didn't have any, that's the reason for denial. Find out if this is the case and what their evaluation process looks like.

I can't see why cognitive impairment should be a criteria. Not everyone has Dementia that needs care. I would appeal. Sending letters from the doctors would be good.

Its a shame that you pay so much for this insurance and there are so many stipulations. Same with those Reversed mortgages. Not all they are cracked up to be.

Actually, JA, after reading your response, I think you might want to reach out to a social worker who has some experience in placement of seniors needing care and ask THEM for some advice.

I know a woman who was applying to be paid by Medicaid to take care of her mom with AZ. After the first interview - in which they were denied - they spoke with another friend, who is a SW who helps arrange for state-paid care for various people - mostly younger, but it's pretty much the same process. She told the daughter she had given wrong answers, and the coached her on what to say at the appeal. It worked, and daughter was able to get paid for taking care of mom.

The insurance company doesn't want to pay "unnecessary" claims, so they're not going to coach you on the "right" answers (if you've seen "The Incredibles" - when Mr. Incredible is "coaching" the woman on what to say and do to get her claim paid, you'll know what I mean) so this is where a SW might be able to give you some insight. Try a local senior center, they might have someone who can give you some pointers.

And, if you weren't there when the company was questioning mom, I would make sure you were around next time. Sometimes for the elderly the decline is so insidious and sneaky, they're not even aware of how much help they need, until the person who has been doing the helping speaks up.

JA, was someone there with her during the in-home assessment?

If not, you need another assessment with some from the family who is not in denial and willing to challenge mom's self-proclaimed "yes, I'm fine" and "yes, I can cook".

My mother, assessed by an OT in rehab said that of course she knew how to dress herself. So the came the next morning while mom was in her nighty and asked mom to demonstrate her dressing skills.

She started with her slacks. It was clear that my mom no longer had the procedural knowledge to do her ADLs.

Badger, So what exactly are you wanting / expecting to use her LTC insurance for? Like to have inhome services for her? or to pay for her costs in a SNF?

Whichever it is, the needs assessment determination that’s central in all this. That in-person in real time assessment gives Insurer cover to deny the claim. Look at the policy, I bet it reads an outside assessment is the determining factor & not her various MD records unless she is in a SNF from a hospitalization discharge. Because of this, her docs did not have to be contacted. If you do not have a copy of all the pages of the assessment, you need to get that. Cause that’s what your up against.

I’m going to guess it reads “no substantial assistance” needed for ADLs and “no cognitive impairment”. Were you there & was it the 3 word and clock drawing test that was done? Aka mini mental tests for cognition. She passed it. To get around this, her internist will need to provide her medical chart history with clock drawings on all the other times the practice has done them this past year / 6 months and her word recognition test scores. If her doc did not do these routinely every visit, and she saw her doc very 4-6 weeks regularly, she will need to get a referral to a gerontology practice who does in-depth cognition tests.

That she doesn’t bathe often or change her clothes often or eat most of her plate in & of themselves is not enough to show substantial assistance needed. What they probably determined was it was not that she cannot do these things but she can do them but chooses not to. Huge difference.

If she knows to get up in the morning & go to bed at nite (so aware of time), dresses appropriately (not so much clean clothes but knows to put on a coat or sweater if it’s cold, knows if she’s naked), if she can transition from bed to standing and use the toilet and asks for/eats meals, and can do most of this on her own or with using a cane or a walker, she’s good on her ADLs. They may have asked her “Mrs Badger what did you do today”, and a current event ? or two; so if she told them she got up and dressed and had oatmeal and complained about the weather and the 2020 election, she’s good on her ADLs and cognition. If she uses a Hoyer lift or is bedfast, or minimal muscle strength, so could not ever transition on her own that’s substantial assistance needed.

3 recent hospital stays!?! OMG!
Why hasn’t she gone into a NH / SNF after being discharged from even 1 of those? Like discharged to rehab unit in a NH? She would have fat medical chart to get beyond any concerns. She’d do her 100% MediCARE paid rehab days then go into 50% MediCARE days and then onto LTC policy once she hit the 50/100 day trigger to have LTC policy paying.
Do her discharge notes (not hospitalization info) show she is totally ok to resume daily activities once she finished specific medications or after a set period of time (like the no activity till after 5 days for some pacemaker battery replacement). Pay attention to this as discharge info may not support “substantial assistance needed”.
Or is this about you / her hoping to have LTC policy pay for care so that she can stay home tended to 24/7 and not ever enter a NH?

On finding an attorney to challenge JH, if you mean to sue JH, that’s not realistic. JH does not sell LTC anymore and hasn’t for almost a decade. JH sold off its LTC biz ages ago. It’s now a free standing division of Manulife, based in Canada, with a contractor who deals with servicing old JH policies.

@Igloo572 said:
3 recent hospital stays!?! OMG! 
Why hasn’t she gone into a NH / SNF after being discharged from even 1 of those? Like discharged to rehab unit in a NH? She would have fat medical chart to get beyond any concerns. She’d do her 100% MediCARE paid rehab days then go into 50% MediCARE days and then onto LTC policy once she hit the 50/100 day trigger to have LTC policy paying. 
Do her discharge notes (not hospitalization info) show she is totally ok to resume daily activities once she finished specific medications or after a set period of time (like the no activity till after 5 days for some pacemaker battery replacement). Pay attention to this as discharge info may not support “substantial assistance needed”.

What does this mean: **She’d do her 100% MediCARE paid rehab days then go into 50% MediCARE days and then onto LTC policy once she hit the 50/100 day trigger to have LTC policy paying. **