How do I answer insurance company questions about my Mother falling and breaking her wrist?

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How do I answer insurance company questions about my Mother falling and breaking her wrist?

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my mother lives in an ass't living home. She gets up once a night to go to the bathroom. 5 weeks ago she fell and broke her wrist and the care giver found her the next morning asleep on the floor. Mom went by ambulance to the hospital. Now the health insurance has asked a 3rd party to ask about the accident and wants insurance info for the ass't living home. I do not feel that the home is responsible at all for my mother falling. Mom turns on the light when she gets up, has a night light, the bathroom has a night light. It was an accident. The home has now put a mattress alarm on my mother's bed so that they will know when she gets up and they will get up with her now. How is it their fault? Mom fell. She fallen here at my house before. What do I tell them?

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Good point, Igloo. I wouldn't even tell them your mom gets up once a night to go to the bathroom. You are not there, so you cannot be sure of that.

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So it's the station that you got a letter from a company on the behalf of your moms health insurance company asking specific ? as to the incident, that's it right?

We've had 4 of these in 15 years. All related to going to the ER and a claim filed. It's standard for questionnaire to be sent. As others have said, insurers are looking to see who else can share the costs paid. If the incident happened on private property, then the property owner will likely get a letter asking for their insurance as your insurance company will seek shared costs from them. Answer in as least # of words possible. You weren't there so probably most ? you cannot answer.

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Just give the insurance company the information you know and nothing more. If the insurance company thinks there could be a third party liability, let them do the investigating.

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They are not required to have an awake person at this home. There are night lights in mom's room, the hallway, and the bathroom. Mom has a touch lamp that she touches to turn on when she does get up at night. Mom does walk around without a walker some of the time but I always have her use one when I take her places just to slow her down some when walking. There are railings along the hallways also. If there were some sort button to push that mom would press to alert the caregiver that she is getting up might help but it would have to be part of the lamp because mom would never remember about the button. She does know that the lamp turns on by just touching it.

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That is what insurance companies do. If they can blame the care home, then they can sue them. It seems that she does not pay for 24/7 care so the home would not be responsible. Then they will look at the type of license in this home to see if by law they are to have an awake night person. If so, then the home may be in some trouble. Are there call lights readily accessible? But, even with an awake night person, they cannot be in all rooms at one time.

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In the area where we live this one particular housing development has a lot on one level homes. These homes are being bought and converted into ass't living homes. The one that my mother is in just open last year and my mother was the first resident. We had to wait to get into this home until all of the state requirements were signed off on and the house got its permit to take people in.The owner is a nurse also but works for a government agency 3-4 days a week. There is a full time live in certified care person also. The house slowly filled up with 4 people. In the evening both were there, the owner lived there also for the first year. This home is certified to be a "age in place" home meaning that my mother could stay there until she passes away. They put a mattress alarm on my mom's bed now so that the care giver is alerted when mom gets out of bed. They also put a motion detector in the hallway so they know when one resident goes to the living room at night. I have full confidence in this home and the lady running it. If it were a bad place then I am sure that the 2 residents that do not have dementia would have left. One lady leaves several times during the week and is picked up by the senior center bus. The other lady calls public transportation and a handicap equipped bus comes for her. My sister and I visited numerous ass't living homes and this one is by far a really nice place. They are constantly adding new things to do like music time by someone who comes in, an exercise person comes 3 x a week, a craft person comes, hair dresser, someone for manicures, pets on wheels, movie night. The list goes on. I am allowed to eat with my mother if I have called a head of time for a small set price. I posted merely to ask why would the insurance company want to try to make someone else pay for my mother's accident.

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Agree with everything above, stick to answering the questions don't offer opinions or explanations. the Insurance company would like to get the homes insurers to cover some or all of the costs if they can. Let those two parties fight it out amongst them selves. A least the care home will have homeowners insurance. If they are operating properly they should also carry liability. In my small opinion with four elderly residents they should have an overnight caregiver or monitors in each room or call buttons for their residents. Is this a small cheaper unlicensed care home. I am not saying you should move Mom but rethink where she is staying. It's like running an unlicensed child care business. Some will care for your child like their own and others let them loose in a fenced yard and find they are eating dog poop. ( My own daughter did that as a toddler in our own yard. Yuck yuck) and she grew up to become a veterinarian!!!!!!!!!!!!!!!

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One word answer: truthfully.

Do not second-guess your insurers. They are not looking for someone to blame, in a forensic sense anyway; they are asking reasonable questions to establish the facts of what happened. Those questions you cannot answer - for the simple reason that you were not on the scene and do not know exactly what happened - you refer to the manager at the ALF.

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You say the insurance company has asked a third party to get more information. If someone asks you directly, tell them the truth which, I assume, is that mom had absolutely no arrangement with the ALF to help her in the middle of the night and it was a simple accident. I would not go out of my way to impede mom's insurance company from doing what they do.

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This is standard operating procedure for insurers. If they can find a way to get out of paying for a claim, they will. Just answer to the best of your ability and get the home to answer the part that is their info, and probably nothing will come of it because it was, as you said, an accident.

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BLS, I hope I didn't suggest that it's a "blame" issue; it's a liability issue, and it's strictly business for insurers.

There's probably an inquiry because the event was a fall, and that can result in a lawsuit. In addition, there are so many ambulance chasing lawyers that an insurance company staff could easily anticipate that one would be involved. Frankly, I'm not surprised that they're not in hospital and nursing home parking lots hovering around like vultures and handing out cards.

I also recall that I was asked once if there was joint liability after something happened to me - I don't even remember what it was.

I suspect that statisticians have identified certain activities and events in which liability can be attributed to another entity, and they're just doing the best to manage their exposure.

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I am the POA for my mother and the person who makes medical decisions for my mother also.

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My mother had fallen at another place that she lived in before this home. I saw bruises and asked about it. She did not remember falling. Turns out that this time the hospital said that there is an old healed fracture on the other side of the same wrist. My mother gets really good care at the home where she lives now. They do not have overnight awake staff, the place has only 4 residents and a live- in care giver. They have now put a mattress alarm on her bed.
I just think that it is ashame that they seem to want to blame somebody for my mother falling so they can make them pay out. The form even asks is I have contacted a lawyer.

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More info, please:

In the post title, you state that you need to respond to the insurance company, and in the body of the post you referred to yourself as a "third party."

The insurance company contacted you specifically for a reason. Do you hold any health care or financial proxies for your mother, and/or are you named in her HIPAA releases? If so, that makes sense that the company would contact you to provide information for your mother.

I've seen a similar instance, which I suspect may be the case here. After my father fell, his secondary health provider requested information on the fall, to determine if there was any liability of the facility at which he fell.

I believe their point was whether or not they could subrogate against the facility where he fell. If you're not familiar with the term, subrogation a process by which liability against a third party is assessed and "negotiations" are initiated to share the medical costs.

"Going after" a facility at fault could allow them to recover some of the medical expenses they paid for your mother's fall, and/or address what they might consider issues that affect the AL's coverage and rates.

That kind of request is legitimate; answer it truthfully and to the best of your knowledge, but don't offer the opinion that you don't feel the AL home is at fault. It isn't an issue of your opinion but rather the criteria by which the insurance underwriters/adjustors will evaluate the claim.

If you don't have insurance info for the AL home, just state it.

It's to your credit though that you don't fault the AL home for the fall.

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How do I answer insurance company questions about my Mother falling and breaking her wrist?

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