I generally reserve this space to comment on medical matters, particularly those related to alternative medicine. However, last month, I became particularly worked up by a scam in which I had become entangled and from which I finally extricated myself, and I decided that I needed this space to vent about it. Long-term care (LTC) insurance has been peddled for years now as a way to insure oneself against unexpected serious illness or injury requiring long-term care. The odds that one will find oneself requiring the services of a nursing home have been estimated at almost 50%. Patients in nursing homes or those requiring long-term home care accrue horrific bills, so the need for insurance for nursing home care appears self-evident. LTC insurance supposedly provides coverage that will provide for the needed nursing care and institutionalization without bankrupting the individual and so will protect one's property, assets, and estate. This is the message pumped out by the LTC insurance industry – one that warns of the big risks of going unprotected and the high likelihood of needing nursing home care and promises peace of mind for seniors. It turns out that all these premises are false, and the LTC industry enjoys fabulous profits while providing very little service to the public.

Long Term Care Insurance – Protection or Scam?
When I purchased a long-term care policy about five years ago, I thought I was giving my wife and I some protection. After all, the promise of being covered in the event of a catastrophic event or terrible illness seemed to make good sense, not only for our health needs but also as protection for our property and money. The insurance carrier put us through the usual extended health questionnaires and insurance physicals, and we were accepted for coverage. We really didn't want to ever imagine ourselves in a nursing home, but the idea that a nurse would be covered if we one day required home care made sense. We bought a policy with the approval of our insurance agent who, as it turned out, had very little information to offer us about how well the insurance company honored claims. Yes, there was an administrative office where we could get forms to file a claim in the event that nursing care was needed. What we didn't know, and what our agent didn't know, and, for that matter, what most everyone doesn't know is that the LTC insurance industry is predicated on establishing policies dedicated to denying payment for nursing home care.

I should have received my first clue of how this industry plays games with insured consumers when I called the administrative office on behalf of my wife to see if her premium payment had been received. I had not been listed in the insurance paperwork as an individual who could be informed about my wife's policy. One had to specifically make the request that one person (and only one), other than the policyholder, could make inquiries about premiums and request nursing care payment. This meant that in the event that one applied for LTC insurance and did not list another party to be effectively a power-of-attorney, the insurance company would speak to no one, including the insurance agent, about the policy and obviously would not be willing to reimburse for care with no communication permitted. The service agents of the company I was dealing with treated me initially as though I was an uninvited fly buzzing through their offices. After securing the right documents, I was allowed to ask about my wife's premium payments but very little information was offered when I tried to understand how I would be able to file a successful claim. I was simply told that I would be given the forms, and then they would process the claim. My insurance agent listened to me politely but was unable to provide any other insights except for offering advice to "review the insurance contract."

In the spring of 2007, I read a report in The New York Times that shocked me to the core. A woman with Alzheimer's disease who has been confined to a nursing home for more than four years has been required to pay 100% for her nursing care, despite the fact that she had an LTC policy that had been fully paid each year for 12 years prior to her admission. Obviously, the patient was in no position to negotiate with her insurance company. However, her daughter was fully capable of submitting all the documents, bills, and doctor reports required for reimbursement. Despite dozens of letters written over the past four years, carefully including all paperwork in meticulous form, her mother's claim was denied each and every time, with the company endlessly demanding additional information and duplicate information, misunderstanding information, and showing a general unwillingness to cooperate. The daughter was well-prepared and skilled in filling out insurance forms and never made any errors in submitting the paperwork, yet the insurance company representatives spent much of their time replying that the paperwork was done improperly. To date, although her mother has inadequate mental functioning to live and care for herself at home and her doctors have certified that she has Alzheimer's and her nursing home care is documented and ongoing, there has been no money provided by the long-term care insurance company. Attempts by The New York Times to ask about this person's case were turned down by the insurance company officials, who declared that they were unable to respond due to HIPPA privacy requirements.

Complaints to Insurance Commissioner Are Increasing
The case described above would seem to be a situation in which the insurance commissioner and politicians should intervene, but the LTC industry is a very powerful insurance group with aggressive lobbyists and lawyer representation. John Hancock Insurance Company, a major player in the LTC industry, put out a public relations letter that claimed that this case was being denied for violation of some policy requirements and that LTC companies by-and-large provide excellent service to insured consumers. The Hancock press release stated that the proof is that there is less than 0.1% complaints made about LTC policies. But The New York Times investigation has shown that the number of complaints to the insurance commissioners has been increasing dramatically over the past five years. Insurance companies know that their bottom line is structured on a simple formula – the less money they pay out, the more profit they make. And the requirements the companies make for nursing care reimbursement are formidable. Despite what agents may claim, it really is within the fine print of the insurance policy – a document that advocates of a patient cannot often easily locate at the time a patient requires long-term nursing care – where the company spells out what must be proven to receive reimbursement.

The standard for active daily living (ADL) requires that the person must not be able to do at least three of the following five activities: dressing, bathing, transferring from bed to chair, walking, and eating. If one were not able to dress and bathe, but could transfer, walk and eat, that would justify an LTC denial.

The fine print gets you in a thousand ways, and it is not a joke. You might pay for your policy for 20 years, but if, when you first filled out your application, you had listed that you were not diagnosed with an ulcer at age 30, but you were, in fact, treated for ulcer when you were 30, your policy will be rescinded, and your coverage denied. Or you might pay for the policy each year for years, but by the time you turn 75, a policy premium that was initially $400/year has become $7,500, and you can't afford the policy. It doesn't matter that you paid for the policy for 20 years; now, you can't afford the premium, and your policy expires, and you get no benefit when you suffer a stroke at age 78. Or you have an active, paid LTC policy, but you develop Parkinson's Disease at age 72. For the first few years, you are able to maintain yourself on the medications provided. However, at age 74, your Parkinson's Disease become incapacitating, and you find yourself bedridden and unable to take care of yourself. Unless you are hospitalized for at least three days prior to being admitted to the nursing home, your LTC policy states that your nursing home care is fully denied. In fact, most nursing homes admit that, unless you receive pre-approval, your nursing home bill is uniformly denied. And, if you are one of the few that do receive LTC reimbursement, your policy generally pays $100-$200 per day after a certain time period, the deductible period when no reimbursement is made. In the event that you do feel that you need home care rather than nursing home care, make sure that your caregiver is an approved nurse; a caretaker who has no approved medical training is another reason for denial. How can you expect any satisfaction when the company hires and pays for doctors to make the final determination that LTC care should be approved?

Long-term health insurance care is necessary to help avoid bankruptcy by paying for needed care. However, this insurance industry is a racket, a scam, a disgrace that should be outlawed and regulated by the federal government. It is even a bigger disgrace that politicians abet the LTC insurance industry. Why we are not policing this industry is testimony to the unlimited power of an insurance contract!

(Duhigg C. Aging, frail, and fighting insurers to pay up. The New York Times. March 26, 2007;A1,A16.)

Liver Disease from a Naturopathic Perspective
One of my earliest memories in setting up an adult medical practice in the early 1980s in Port Townsend, Washington is the feedback I received from the local medical community regarding natural treatment for liver disease. Basically, most docs did not believe that there was any creditable evidence that natural therapies offered any benefit to a "sick" liver. Silymarin (milk thistle extract) was unproven and could not offer any benefit to an individual suffering with liver infection or fibrosis. Vitamin C was not of benefit for colds – how could it be of any benefit in treating hepatitis? Chinese herbal medicine was without scientific foundation and certainly should be avoided for the patient suffering from severe liver disease. In effect, the local physicians advised patients that the remedies I offered them were useless and possibly risky from a safety perspective. These physicians were willing to ignore scientific literature examining silymarin and vitamin C, particularly if the medical community as a whole doubted the effectiveness of these remedies. Anecdotally, I was quite impressed when natural therapies were of considerable benefit in treating patients in my practice.

I am delighted that Burton Berkson, MD, PhD was willing to write a few thoughts in this issue of Townsend Letter on his seminal work in treating acute liver failure and hepatitis. Dr. Berkson's research on alpha lipoic acid's effect on liver pathology is illustrated in his discussion of his treatment of an individual who had been poisoned. Typically, liver failure is untreatable and requires emergency liver transplantation for survival. Berkson observed that the administration of intravenous alpha lipoic acid was instrumental in enabling this individual to survive liver failure. Berkson now uses alpha lipoic acid to treat all liver pathologies.

Jonathan Collin, MD