Letter: Our battle with the insurance company

Our mother, who is 89 years old, was fiercely independent. Up until recently, she was Living alone and even working as an assistant kindergarten teacher.

About 8 months ago, she collapsed with double pneumonia and almost lost her life. While recovering from this, she suffered a stroke which
subsequently robbed her of her independence – with which she was so proud.

We applied for 24-hour help with the insurance which her therapists from the rehab center insisted was the only safe option for her. The
insurance determined, that contrary to what the center insisted on, she only needs 8 hours. Under pressure, we took her home while appealing
this decision and paying out of pocket for the rest of the hours in order to keep her safe.

By the appeal, the insurance deliberately ignored their own nurse’s recommendation for 24 hour help, and insisted on keeping the 8
hours. When we asked what happens if she needs the ladies room and tries to get up herself and fall (which happened a few times in the
rehab center) or needs the cpap machine reconnected – which falls out and with which she needs, to prevent pneumonia again – they had no real answer.

We appealed again, which basically meant that their doctor would look at the paperwork – without letting us have a say- and make a determination. Of course, it was denied again.

As of this moment, we are heading for a hearing with an outside judge. The cost for us in paying the rest of the hours, which is needed for
my mother’s safety, is over $10,000 so far, since every week is $800. We can’t afford to keep paying this, since we are all trying to make ends meet just with our own households. We desperately need help in continuing the ongoing care for our mother to keep her safe and healthy while going forth with the hearing.

If anyone can help out with a suggestion of where we can go for help, please let us know. It would be greatly appreciated.

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  1. Unfortunately, many of us have gone through this before, and if the family can’t care for a person the other hours, and the situation is unsafe the only other option is a nursing home.

    Is this a regular medical insurance or long term care?

  2. Unless this a long term care plan, which is highly unlikely. Insurance companies provide medical care. caring for a disabled individual is not covered. Your may need to start considering nursing home placement for your mother.

  3. I am a nurse working in a LTC facility in NJ and we have this all the time with our residents. Often after a serious medical event the elderly are unable to return to their prior living conditions, even if they were completely independent before. There are a few options at this point… To move in together with one of their children, move into a LTC facility, or hire help during the time that insurance doesn’t cover. I have rarely seen any patients that were approved for 24 hour care at home from insurance.

  4. I know exactly how you feel. I wrnt through the same thing. If she went through the holocaust. Call the claims conference in new york or if she lives in Brooklyn contact the Bikor Cholem

  5. If your mother is in New York State she may be eligible for 24 hour home care under Medicaid. There is an advocacy group called CIDNY acronym for Center for Independence of the Disabled in New York 841 Broadway Suite 301 New York, N.Y. 10003 Phone # 646-442-1788 http://www.cidny.org. They were very understanding and ready to go for a hearing with me at no cost! At the end I didn’t need them.They may be able to help you with your private insurance.

  6. Medicaid is for poor people. OTOH, If she worked, she probably is eliglible for Medicare. You can ask them to cover some of the time – maybe another 8 hours. You won’t get
    24hrs. Also you probably can have them come in & out – to make the most of the time. Nursing Home is the worse idea!

  7. I would recommend therapy at home to maximize hEr independence, be provided education and perhaps have another individual aroundwho may have ideas to help

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