After several repairmen couldn’t fix the problem, Ms. London called the company that administers the extended warranty she bought from Whirlpool. A rep there told her that the warranty didn’t cover her refrigerator. Why?

“It has a pre-existing condition,” she recalled the rep explaining to her.

“I was actually speechless,” Ms. London wrote.

The Haggler, on the other hand, was not speechless. He was laughing. And when he was done laughing, he forwarded the e-mail to a Whirlpool publicist, Nicole Hall. A day later, Ms. London wrote again.

“Nicole called me — they are replacing my refrigerator!” she wrote. “I can’t believe it.”

Believe it. And hope the new fridge is healthy.

O.K., enough mirth. Now let us segue to a topic that actually involves health care and, sorry to say, is not very amusing.

Q. In 2002, my mother-in-law, Beverly Schultz, bought a long-term health care policy from the Continental Casualty Company, a subsidiary of the CNA Financial Corporation. She has since made more than $32,000 in premium payments.

Last September, she suffered a stroke. She was left with the problem-solving and safety awareness equal to a 6-year-old, according to the hospital. When a doctor asked her to name the president, she was stumped — even when told that his first name is Barack. We were instructed to move her to an assisted-living facility.

At 74, she can no longer be trusted to drive, ride her bicycle to the store, use a stove or remember to take her medicine. She is, in short, the very definition of someone unable to care for herself.

For five months, we tried to get CNA to conclude that it ought to cover the $4,000 a month in assisted-living costs to which my mother-in-law is entitled under the terms of her policy. It’s been an ordeal. Instead of asking for all information upfront, CNA made a series of requests in drips and dribbles, each time leaving the impression that once this new information was provided, the case would be resolved. It took days for phone calls to be returned. With each contact we got a new person, who provided different advice and asked for different information.

That’s bad enough. But after countless calls, e-mails and faxes, CNA denied my mother-in-law’s claim, asserting that she didn’t qualify for benefits. I have no idea how we’ll find the money for the care she needs.

Can you give this a shot?

Pete Kotz

Lakewood, Ohio

A. Those of you scoring at home — and, really, who isn’t? — know that the Haggler’s career record as a consumer pugilist is roughly 200 wins and one loss. What explains this lopsided history?

Picking the right opponents. And that means avoiding insurance companies. Generally, these companies don’t actually fight. They simply stand back and say, “Hey, we’re just following the definitions of the policy,” or words to that effect.

The Haggler’s one loss came at the hands of an insurer. Did the Haggler learn from this experience? No.

A spokeswoman for CNA, which is based in Chicago, sent the Haggler a lengthy and detailed letter explaining why the company says Ms. Schultz does not meet the definition of “chronically ill” as detailed in her policy and is therefore not qualified for benefits. The company said a rep from a home care agency visited Ms. Schultz two weeks after her stroke and wrote in a report that she likes to read and do Sudoku puzzles, and “stays active with household chores.”

CNA also cited the findings of Dr. Maja Visekruna, who is not affiliated with the insurer and who examined Ms. Schultz on Sept. 28. In her report, Dr. Visekruna said Ms. Schultz did not have any motor deficits. As CNA put it, “There is no mention of any concern for Mrs. Schultz’s safety, and her orientation to person, place and time was normal.”

The Haggler is condensing, but additional evidence is laid out, and then conclusions are drawn — that Ms. Schultz’s records do not suggest that she suffers from severe cognitive impairment, and that she therefore doesn’t qualify for benefits.

Mr. Kotz says he believes that all of this is bunk. That talk about Sudoku puzzles, chores and reading was, he says, his mother-in-law describing her former self, unaware that she was no longer capable of those activities. And CNA has cherry-picked Dr. Visekruna’s conclusions, he adds. He says that under a section titled “administration of medicine,” the doctor wrote, “She needs help — memory loss.” Under a section titled “Diagnosis causing the need for long-term care services,” the doctor wrote: “S/P CVA, Dementia, ” says Mr. Kotz, who adds that this is medicalspeak for “status post cerebrovascular accident, dementia.” 

“In other words,” Mr. Kotz writes, “dementia caused by or subsequent to a stroke.”

The Haggler duly forwarded Mr. Kotz’s rebuttal to CNA, expecting to hear another take on “Look, the policy is the policy.”

That is not what happened. In a thoroughly startling conversation, a CNA spokeswoman, Jennifer Martinez-Roth, explained that the company would re-examine Ms. Schultz, using an independent physician who specializes in dementia. Also, the company will dispatch a “senior officer” to meet with her family to discuss this case. A letter outlining all of this was just sent to Mr. Kotz.

“This is the best thing to do for the family,” Ms. Martinez-Roth said.

No doubt, that is true. The Haggler is happily amazed. And hopeful. After Ms. Schultz is re-evaluated, look for an update in this space.

E-mail: haggler@nytimes.com. Keep it brief and family-friendly, include your hometown and go easy on the caps-lock key. Letters may be edited for clarity and length.

Article source: http://www.nytimes.com/2013/03/24/your-money/a-winding-road-to-benefits-from-long-term-care-insurance.html?partner=rss&emc=rss