Opinion ID: 871065
Heading Depth: 3
Heading Rank: 2

Heading: Ms. Spiller's Claim for Benefits Under Her Long-Term Care Policy

Text: According to the terms of Ms. Spiller's Policy, policyholders are eligible for benefits when classified as chronically ill. Chronically ill is defined in the Policy as being certified by a licensed health care practitioner within the year prior to applying for benefits as: a) being unable to perform (without Hands-on Assistance from another individual) at least two Activities of Daily Living [(ADLs) ] [3] for a period of at least 90 days due to a loss of functional capacity; or b) requiring Substantial Supervision [4] to Protect Yourself from threats to health and safety due to a Severe Cognitive Impairment. [5] The Policy requires a policyholder to establish a Severe Cognitive Impairment by: (1) incorrectly answer[ing] four or more questions on the Short Portable Mental Status Questionnaire, (2) achiev[ing] a score of 23 or lower on the Folstein Mini-Mental Status Exam (Folstein), or (3) [e]xhibit[ing] specific behavioral problems requiring daily supervision, including but not limited to: wandering, abusive or assaultive behavior, poor judgement [sic] or uncooperativeness which poses a danger to them or others, extreme bizarre personal hygiene habits. In May 2007, after Ms. Spiller applied for long-term care benefits, MedAmerica's third party vender hired registered nurse Michael Kahalekulu (Mr. Kahalekulu) to perform a Benefit Determination Assessment (BDA) on Ms. Spiller, as required by her Policy. Through the BDA, Mr. Kahalekulu concluded that Ms. Spiller needed supervision because of her seizures. She was also unable to perform two ADLs. Hence, claims handler Annette LaFica (Ms. LaFica) approved Ms. Spiller's benefits by letter (on Hartford stationery) on October 17, 2007. At this time, Defendants recommended that Ms. Spiller have 24-hour supervision. Defendants contend that in October 2007, Defendants gave Ms. Spiller only conditional approval that was subject to reassessment. [6] Moreover, Defendants claim Ms. Spiller originally failed to demonstrate that she was sufficiently impaired (through either ADLs or cognitively) to qualify for benefits under her Policy in May 2007. In fact, they maintain that Ms. Spiller understood her benefits were conditional when Defendants approved them in October 2007. [7] Mr. Kahalekulu performed a second BDA for Ms. Spiller on December 21, 2007. The second BDA indicated that she required assistance with at least three ADLs, specifically bathing, transferring and dressing. Also, Ms. Spiller had a Folstein score of nineteen, which indicated she had Severe Cognitive Impairment, and qualified for continued long-term care benefits. Accordingly, Defendants extended Ms. Spiller's benefits through June 30, 2008. Mr. Kahalekulu performed a third BDA for Ms. Spiller on July 28, 2008. Ms. Spiller argues that this BDA indicated she required assistance with two ADLs, specifically, bathing and dressing. Also according to the third BDA, Ms. Spiller's Folstein score increased to twenty-five, though she claims she still required supervision due to her cognitive impairments. After Ms. Spiller's third BDA, Defendants terminated her benefits. Barbara Mottern (Ms. Mottern), Hartford/MedAmerica's new contact ( i.e., replacing Ms. LaFica who previously handled Ms. Spiller's claim), telephoned Ms. Spiller and informed her that Hartford/MedAmerica was terminating her long-term care benefits on August 25, 2008. Mottern explained that Ms. Spiller was no longer classified as cognitively impaired or incapable of performing two ADLs as required by the Policy. On August 22, 2008, Ms. Mottern recorded in her NotePad Report: Insured no longer meets cog. triggerin fact did very well on testing. Needs assist[ance] with Bathing, Dressing for sleeves but lives in tropical climate on island of Maui [sic] Discovered caregiver is sig. otherwho resides with insured. Falls under exclusion of if no charge would be made in the absence of insurance.... Will approve thru September 6, 2008 due to lack of tim[e]liness on our part. Defendants terminated Ms. Spiller's benefits as of September 2, 2008 (an August 25, 2008 entry reads `Error in above notepad dated 8/22/2008: Approval to 8/31/2008, denied assessment # 4.'). Defendants' September 19, 2008 letter (on Hartford stationery) confirmed Ms. Spiller's benefit termination. Defendants maintain that the July 28, 2008 BDA rendered Ms. Spiller ineligible for benefits. Specifically, they contend that Ms. Spiller required help with only one ADL, bathing. Defendants argue it was reasonable to surmise that Ms. Spiller failed to meet the ADL for dressing because the July 28, 2008 BDA was inconsistent with her prior ADLs for dressing. Particularly, the July 28, 2008 BDA contained inconsistencies regarding the frequency she needed help dressing ( i.e., daily, when needed, at times). More notably, Defendants cite to Mr. Kahalekulu's statements that Ms. Spiller needed assistance with dressing with sleeves on tops, and that she at times has difficulty putting on pull-over tops and needs assistance from [Mr. Kahae]. Moreover, Defendants contend that because Ms. Spiller's Folstein score exceeded the eligibility threshold of twenty-three, the BDA's conclusion that Ms. Spiller needed help dressing because of confusion is irrelevant. Also, Defendants stress they were waiting, after several requests, for Ms. Spiller's medical records from her treating physician, Dr. McGuire, [8] and maintain that no other medical record explains the frequency or severity of her seizures. [9] Also, Defendants emphasize that because Mr. Kahalekulu was a third party vender, they were entitled to conduct their own assessment of Ms. Spiller in order to confirm her eligibility. The District Court explains that Ms. Mottern appears to have taken issue with benefits being paid to [Mr.] Kahae, [Ms.] Spiller's live-in companion. Ms. Mottern recorded that Mr. Kahae [10] falls under exclusion of `if no charge would be made in the absence of insurance.' Here, Ms. Mottern referred to the Policy exclusion for any expenses incurred... for which no charge is normally made in the absence of insurance. Even so, Defendants previously approved Ms. Spiller's benefits with knowledge that she received care from a private caregiver ( i.e., Mr. Kahae) under an Alternative Care Benefit provision which allowed benefits for providers, treatments[] or services otherwise specified in the Policy if cost effective, appropriate and consistent with general standards of care. In other words, Defendants apparently knew of, and approved, [Ms.] Spiller's situation with [Mr.] Kahae. Ms. Mottern raised this issue with Ms. Spiller in their August 25, 2008 telephone conversation. However, Defendants do not assert that this was a basis for terminating Ms. Spiller's benefits. Nevertheless, some evidence in the record suggests that Ms. Spiller believed that her Policy exclusion was a basis for her benefit termination. [11] Additionally, Ms. Mottern questioned whether Mr. Kahalekulu was biased in his assessment because he became friends with Ms. Spiller. [12] When Ms. Spiller spoke with Ms. Mottern regarding her benefits termination in September 2008, Ms. Mottern wanted to schedule another BDA. Ms. Spiller requested that Mr. Kahalekulu conduct the assessment, but Ms. Mottern denied her request. Ms. Mottern's September 19, 2008 letter to Ms. Spiller approved Ms. Spiller's request to appeal her benefit termination. Ms. Mottern then scheduled another BDA.