Facing challenges with your long-term care (LTC) insurance claim can feel like battling a storm with no end in sight. Whether it is for yourself or a loved one, the need for long-term care can bring with it not just concern for health and well-being but also significant anxiety about managing the costs involved.
Long-term care insurance is supposed to provide security in these times, ensuring that the necessary care does not drain your life savings. However, when faced with denied claims or disputes with insurance companies, this safety net can feel like it is being pulled away just when you need it most.
Dealing with insurance companies can sometimes feel like a battle against an impersonal bureaucracy. Policies are often filled with fine print, and the process can seem overwhelming. It is easy to feel lost in the shuffle, unsure of where to turn for help.
At Kantor & Kantor, we understand these difficulties. Our San Diego LTC insurance lawyers are more than just legal representatives; we are people helping people. We are committed to helping you secure the coverage you rightfully deserve.
Contact us at 858-758-4231 for a free consultation.
What is Long Term Care Insurance?
Long-term care 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.
We offer a free case evaluation to discuss how our attorneys can assist you. Contact us now at 818-886-2525 for your free consultation.
Why Was Your LTC Claim Denied?
While LTC policies offer valuable protection, policyholders face various challenges when accessing benefits. Below are some common obstacles policyholders may encounter:
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 canceled 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. Further, lapses can, and do, occur as a result 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 in order to deny a claim.
How To Appeal a Long-Term Care Insurance Denial
A long-term care denial is not the end of the road. You have the right to appeal the decision, and with the right approach, you can increase your chances of securing coverage.
Firstly, start by carefully reviewing the denial letter sent by your insurance company. This letter should outline the specific reasons why your claim was denied. Understanding these reasons is crucial, as it will guide your appeal process and help you address the issues directly.
Next, it is time to dig into your policy. Re-read the terms and conditions, focusing on the sections related to coverage, exclusions, and the claims process. It is not uncommon for policy language to be complex and confusing, so do not hesitate to seek clarification. If you find it difficult to decipher the policy, consulting with a lawyer who specializes in insurance law can provide valuable insights and ensure you are on the right track.
Documentation is key in the appeal process. Gather all relevant medical records, care plans, and any other supporting documentation that demonstrates the necessity of the long-term care services you are seeking. It is essential to present a comprehensive and organized set of documents to build a strong case. Additionally, obtaining a letter from your healthcare provider that clearly outlines your medical condition and the need for specific long-term care services can significantly bolster your appeal.
As you prepare your appeal, write a detailed and persuasive letter that addresses the reasons for the denial and presents your case clearly and concisely. Explain why the insurance company’s decision was incorrect and provide evidence to support your arguments. Be respectful but firm in your communication, and remember to include all necessary documentation as attachments to your letter.
Submitting your appeal on time is crucial. Insurance companies often have strict deadlines for filing appeals, typically outlined in your policy or the denial letter. Missing this deadline could jeopardize your chances of a successful appeal. If you are unsure about the timeframe, contact your insurance company to confirm the deadline and the specific steps required to file the appeal.
If your appeal is denied, do not be discouraged. There are still options available. You can request a second-level appeal, seek mediation, or even take legal action. Each step can be more complex and may require additional evidence and arguments. Having a long-term care attorney in San Diego by your side can provide the support and expertise you need to navigate these next steps.
Why Choose Kantor & Kantor?
When it comes to handling LTC insurance claims, having the right legal team by your side can make all the difference. Here is why Kantor & Kantor is the best choice for you:
1. Experience That Matters
Our team has years of experience dealing with insurance companies and their tactics. We have seen it all, from policy exclusions to claims of insufficient documentation. This experience means we know how to anticipate and counter the strategies insurers use to deny your rightful claims.
2. Empathy at Every Step
We know that behind every claim is a story. A story of someone’s mom, someone’s grandfather, or a loved one who needs help. That is why we approach each case with a blend of professional rigor and genuine care. Your struggles are real to us, and so is our commitment to resolving them.
3. A Team That Fights for You
We are not afraid to take on big insurance companies to protect your rights. If your claim has been unfairly denied, we are here to challenge those decisions aggressively and persistently. We fight not just for your claim but for your peace of mind and the care you deserve.
4. Proven Success
Our success stories speak for themselves. We have helped numerous clients achieve favorable outcomes and get the care they deserve. We are committed to fighting for your rights and making sure you receive the coverage you have paid for.
5. Client-Centered Approach
At Kantor & Kantor, you are more than just a case number. We take the time to get to know you and your situation. This approach allows us to tailor our strategies to meet your needs. We keep you informed and involved throughout the entire process because your peace of mind is important to us.
How We Can Help
We understand that dealing with LTC insurance issues can be as personal as it is complex. Our San Diego LTC attorneys are here to ensure you never feel like just another case file. Here is what we do to help:
1. Complete Policy Review
The dense and often confusing language can make understanding your LTC insurance policy difficult. Our team will meticulously review your policy to identify the coverage details, benefits, exclusions, and any potential issues that might arise. We will explain the terms in plain language, ensuring you fully understand your entitlements and obligations.
2. Claim Filing Assistance
Filing a LTC insurance claim requires detailed documentation and strict adherence to the policy’s procedures. Our attorneys will assist you in preparing and submitting your claim, ensuring all necessary documentation is included and accurately completed. By proactively managing the claim filing process, we help minimize the risk of delays or denials.
3. Appealing Denied Claims
Insurance companies may deny claims for different reasons, often leaving policyholders feeling helpless. If your claim has been denied, our San Diego LTC insurance lawyers will conduct a thorough investigation to understand the basis of the denial. We will then prepare a comprehensive appeal, challenging the denial with strong legal arguments and supporting evidence. Our team is dedicated to reversing unjust denials and securing the benefits you deserve.
4. Addressing Policy Lapses
Policy lapses or cancellations can occur for various reasons, including missed payments or administrative errors. If your policy has lapsed, we will investigate the circumstances and work to reinstate your coverage. We will also advise you on steps to prevent future lapses, ensuring continuous coverage and protection.
5. Coverage Disputes
Disputes over what services are covered under your policy, or the manner in which they are covered, can lead to confusion and denial of necessary care. Our lawyers are adept at interpreting policy language and will advocate for your rightful coverage. We will engage with the insurance company to clarify ambiguities and ensure you receive the full range of benefits your policy provides.
6. Litigation Support
In some cases, legal action may be necessary to secure your benefits. Our firm is prepared to take your case to court if needed. With extensive experience in litigation, our attorneys will build a compelling case and represent you vigorously in legal proceedings.
Contact Our San Diego LTC Insurance Lawyers Today
If you or a loved one are struggling to get the LTC insurance benefits you rightfully deserve, we are here to fight for you.
At Kantor & Kantor, we understand more than the legal implications of your LTC insurance claim—we understand what is at stake for you and your family. It is not just about forms and paperwork; it is about securing the care and support needed to maintain quality of life in challenging times.
We are not just lawyers; we are people helping people. With Kantor & Kantor, you are not just hiring a lawyer; you are gaining a partner who will stand by you every step of the way.
Contact our San Diego long-term care insurance lawyers at 858-758-4231 for a free consultation.
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]
