When you took out a long-term care insurance policy, you were planning ahead. You paid your premiums, trusting that the insurance would be there when you needed it the most. Unfortunately, when the time comes to claim those benefits, they are denied or delayed, leaving you stranded.
Long-term care insurance policies are complex, filled with legal jargon, strict definitions, and technical requirements that can be hard to navigate without help. Insurance companies may say your care is not “medically necessary,” that your facility is not “licensed,” or that you have not met the so-called “benefit triggers.” For someone trying to get through a difficult time, these roadblocks can feel impossible to overcome.
Our experience with long-term care insurance claims has shown us the myriad ways insurers attempt to deny legitimate claims. We have built our practice on standing up to insurance companies and advocating for policyholders just like you.
If your long-term care insurance claim has been denied or delayed, or you are simply unsure of what steps to take, we are here to help. We offer free consultations and will always give you honest, straightforward guidance.
Contact our Oregon long-term care insurance lawyers at 818-886-2525 for a free consultation. We are people helping people, and we are ready to help you get your long-term care insurance benefits.
What Is Long-Term Care?
Long-term care (LTC) insurance is an insurance policy designed to cover the costs of long-term services and support, including personal and custodial care. This care is typically provided in various settings, such as the insured person’s home, an assisted living facility, or a nursing home. The primary purpose of long-term care insurance is to help individuals manage the potentially high costs associated with long-term care due to chronic illness, disability, or aging.
Qualifying for LTC insurance involves meeting specific criteria related to age, health, and the insurance company’s underwriting guidelines. Insurance companies assess potential policyholders based on factors that predict their likelihood of needing long-term care in the future. The six Activities of Daily Living (ADLs) are basic self-care tasks that are essential for independent living, and these tasks are commonly used to assess a person’s ability to function and determine the level of care they may require, particularly when applying for long-term care insurance or benefits. The inability to perform a certain number of these ADLs often qualifies a person for assistance or long-term care benefits.
The following are the six ADLs:
- Bathing: The ability to wash oneself in the bath or shower, including the ability to get in and out of the tub or shower safely.
- Dressing: The ability to select and put on appropriate clothing, as well as being able to take the clothes off when needed. This also includes tasks like fastening buttons and zipping zippers.
- Eating: The ability to feed oneself, including bringing food to the mouth and chewing/swallowing, but not necessarily the ability to prepare meals.
- Transferring: The ability to move from one place to another, such as getting in and out of bed, standing up from a chair, or moving to and from a wheelchair.
- Toileting: The ability to use the toilet, including getting on and off the toilet, maintaining hygiene, and managing personal hygiene related to continence.
- Continence: The ability to control both bladder and bowel functions or manage incontinence effectively if necessary.
However, generally, there are two separate ways to qualify for LTC insurance: Be physically impaired and thus unable to perform two of the six ADLs; or have severe cognitive impairment.
What Are the Different Types of Long-Term Care Services?
Long-term care services are typically provided in the following settings:
- Home Care: Many individuals receive care at home, often from family members, for both short-term recovery and ongoing needs. However, some insurance policies may not cover care provided by unlicensed family members.
- Nursing Homes: These facilities offer both medical and personal care for individuals who are no longer able to manage daily tasks on their own.
- Assisted Living Facilities: This is designed for those with chronic illnesses or disabilities. These facilities provide daily support with activities like bathing, dressing, and eating, along with medical supervision.
- Intermediate Care Facilities : These serve individuals with mental disabilities or declining health who require more support than what is typically offered in elderly care and may be covered by long-term care insurance.
- Continuing Care Retirement Communities (CCRCs): CCRCs offer a range of living options like independent living, assisted living, and skilled nursing within a single community for seniors aged 62 and older. As needs change, residents can move to a higher level of care while using their long-term care insurance to cover various services.
Why Was Your LTC Claim Denied?
Insurance companies can often seem like they are on your side until you file a claim. When it comes to long-term care insurance, there are several reasons why an insurer might deny a claim. Here is a look at why these denials can happen:
1. Substantive Denial of Claims
One of the most frustrating challenges policyholders face is the denial of their insurance claims due to disputes over the necessity of the care provided.
2. Policy Lapses and Cancellations
Policyholders may inadvertently allow their LTC insurance policies to lapse or be cancelled due to missed premium payments or other administrative errors. While your policy may lapse, insurance companies must alert you to the lapse and provide proper notice. Furthermore, lapses can, and do, occur because of the insurance company’s error. If you notice the mistake before you need to make a claim, the insurer will often require you to reapply for the insurance and deny coverage.
3. Coverage Disputes
Disputes over what services are covered under a LTC insurance policy are not uncommon. Policyholders may disagree with their insurance companies regarding the scope of coverage for specific care services, leading to confusion and frustration. These disputes can prolong the claims process and create additional stress for policyholders and their families.
For example, while some policies cover at-home nursing care, other policies only cover nursing homes. All policies have requirements for both. Ultimately, even if an insurer agrees that a person needs and qualifies for care, the insurance company may argue that the person is not receiving care from a qualified person/entity to deny a claim.
What to Do if Your Long-Term Care Has Been Denied
When facing a long-term care insurance claim denial, It is essential to understand why your claim was denied. Insurance companies are required to provide a clear explanation for the denial in their correspondence. Review the denial letter carefully. It should explain the reason for the denial, though the language might be technical or unclear.
Once you know the reason for the denial, gather all relevant documents related to your claim. This includes your insurance policy, any correspondence with the insurance company, medical records, proof of your attempts to comply with policy requirements, and any other documentation that supports your need for long-term care.
It is also important to act quickly. Most long-term care policies have strict deadlines for filing an appeal. Waiting too long could limit your ability to fight the denial or even forfeit your claim altogether.
In your appeal, be as detailed as possible, citing specific policy language and medical evidence that supports your case. It is not uncommon for initial denials to be overturned during the appeals process when presented with compelling evidence and a well-argued case.
If you believe the denial is wrong or even if you are just unsure, it is smart to speak with a long-term care insurance attorney. A lawyer can help you interpret your policy, identify where the insurance company may have gone off track, and guide you through the appeals process. At Kantor & Kantor, we have helped individuals and families push back after a denial, and we know how to deal with insurers who are not playing fair.
Why Choose Kantor & Kantor?
We are people helping people, who show up every day to help people just like you. You have paid into an insurance policy, only to be met with silence, red tape, or a flat-out denial when you need help the most.
We have been doing this for decades, and if there is one thing we have learned, it is that insurance companies do not always play fair. But we do. And we play to win.
Here are some reasons why you should choose us:
Experienced Attorneys
Our attorneys focus on insurance law and have extensive experience representing clients in various types of insurance cases. We understand the intricacies of LTC insurance policies and know how to effectively advocate for our client’s rights.
Proven & Solid Track Record
With a history of successful case outcomes against insurers and successful LTC settlements for clients, we have built a reputation for excellence in the legal community. We have helped numerous clients secure the benefits they deserve, even in the face of denied claims and complex legal challenges.
Tenacious Advocacy
We are relentless when pursuing justice for our clients. When insurance companies act in bad faith or unfairly deny claims, we do not hesitate to challenge them. Our lawyers are skilled negotiators and formidable litigators who will fight for your deserved benefits.
Comprehensive Legal Support
From the initial consultation to your case’s resolution, we provide comprehensive legal support. We handle all aspects of your claim, including policy review, claim filing, appeals, and litigation. Our holistic approach ensures no detail is overlooked and you receive the full legal services needed to secure your benefits.
Contact Our Oregon Long-Term Care Insurance Lawyers Today
You should not have to become an expert in long-term care insurance just to get the benefits you are entitled to. That is our job. We know how to decode the fine print, challenge unfair denials, and, when necessary, take legal action. We have handled cases involving all the major insurers, and we are not afraid to hold them accountable.
If your claim has been denied, delayed, or underpaid, it absolutely does not mean the fight is over.
Contact our Oregon long-term care insurance lawyers at 818-886-2525 for a free consultation. We will give you an honest opinion about your options and how we can help.
Attorney Glenn R. Kantor
Glenn Kantor is a founding partner of Kantor & Kantor LLP. As a young attorney, Glenn saw the injustice of wrongful insurance denials and created a law firm to represent individuals seeking to obtain their rightful benefits. Glenn is committed to ensure that clients receive the benefits they are entitled to under their insurance policies or group health plans. [Attorney Bio]
