Getting the runaround on long-term care insurance

She said she was told by a Washington National service rep that the company's decision was final, so no further appeals would be considered.

I got in touch with Barbara Ciesemier, a Washington National spokeswoman. She declined to delve into details of Corwin's case, but she said by email that the insurer "acted in accordance with policy provisions."

"It is our objective to pay all claims in a timely manner, consistent with the terms and conditions of our policies," Ciesemier said.

She said approval of claims "is not triggered by a medical diagnosis, but determined by the care that is required due to that sickness or injury."

"These policies have a maximum benefit limit per occurrence or period of care," Ciesemier continued. "Once the per-occurrence maximum has been reached, no additional benefits are payable unless the insured qualifies for a new occurrence."

This is the same brick wall Corwin ran into. Washington National isn't acknowledging that the two claims resulted from two different medical problems.

Moreover, Ciesemier seems to be saying that the doctor's diagnosis wasn't even a factor in denying the claim. Rather, the insurer focused solely on the fact that the services of a caregiver were once again required.

Ciesemier's insistence that Washington National "acted in accordance with policy provisions" is belied by its own policy language, which states that a single "occurrence" is defined as being "due to the same or related cause."

I pointed out this seeming contradiction to Ciesemier.

She said only that "the deciding factor is based on the entirety of the policy language and the individual circumstances, not simply one provision of the policy."

I asked what that meant. Ciesemier said she'd have no further comment.

First of all, Washington National's denial letters cite only the "per-occurrence" provision in rejecting Corwin's claim. No other reason is given.

Moreover, I've read the entire insurance policy. I couldn't find any language that in any way redefines the nature of an "occurrence."

Nor could I find any mention that approval of claims "is not triggered by a medical diagnosis" but rather by "the care that is required."

In fact, the policy explicitly states that home healthcare must be "prescribed in a plan of care by a physician."

Washington National appears to be acting in bad faith in dealing with a longtime customer for no better purpose than to save itself some money.

If the company is so sure it's in the right, it shouldn't hesitate to explain itself plainly, to Corwin if not to me. The fact that it chooses to hide behind corporate gibberish suggests it knows perfectly well that its actions are indefensible.

Steven M. Stecher, who pulled down $2.1 million in total compensation last year as president of Washington National, is more than welcome to prove me wrong.

David Lazarus' column runs Tuesdays and Fridays. He also can be seen daily on KTLA-TV Channel 5 and followed on Twitter @Davidlaz. Send tips or feedback to david.lazarus@latimes.com.

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