When you invest in long-term care insurance, you do it with the hope that when the time comes, your policy will be there to support you. You expect it to cover the cost of nursing-home care, assisted living, or in-home assistance—whatever you need to maintain your quality of life. Unfortunately, for many policyholders, getting their insurance company to honor their policy is an uphill battle.
At Kantor & Kantor, we have seen too many people face unnecessary delays, lowball settlements, or outright denials from their insurance providers. These companies often use complicated policy language and technical loopholes to avoid paying claims.
Insurance disputes can be overwhelming, especially when you are already dealing with health challenges. We have spent years holding insurance companies accountable and have helped countless clients overturn wrongful denials and delays.
We understand the tactics insurers use to avoid paying claims, and we know how to push back. Whether your claim has been denied outright or you are facing unreasonable delays, we are here to help. Contact our Tacoma long-term care insurance lawyers at 818-886-2525 for a free consultation.
We are people helping people and we have the resources to fight for your long-term care 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 LTC 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 LTC 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 primary 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.
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:
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.
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.
Coverage Disputes
Disputes over what services are covered under an 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 cover only nursing homes. All policies have requirements for both. Ultimately, even if an insurer agrees that a person needs and qualifies for care, to deny a claim the insurance company may argue that the person is not receiving care from a qualified person/entity.
Steps to Take After Your Long-Term Care Case Has Been Denied
The first step is to carefully read the denial letter from the insurance company. It is crucial to understand their reasoning as it outlines specific issues or missing information, which can be critical for forming your appeal.
The letter often mentions whether the denial is due to not meeting the policy’s criteria, to insufficient documentation, or for other reasons. Knowing exactly why your claim was denied will help in addressing these points effectively.
Once you understand the reasons for denial, revisit your insurance policy. Look at the definitions and provisions related to qualifying for long-term care. Understanding the language of your policy is essential to argue against the insurance company’s interpretation or to correct misunderstandings in your initial application.
Start collecting all necessary documents that support your claim. This includes medical records, statements from your healthcare providers, and any previous correspondence with the insurance company. Documentation should explicitly support the criteria outlined in your insurance policy for long-term care needs.
It should be a priority to hire a long-term care insurance lawyer. An experienced attorney can offer a comprehensive review of your case, advise you on the best course of action, and help in preparing an appeal. They understand the insurance law and will ensure that your appeal addresses all the technical and procedural requirements.
With your lawyer’s help, prepare and submit a formal appeal to the insurance company. This appeal should clearly address the reasons for denial mentioned in their letter, backed by strong evidence and documentation. Ensure that your appeal adheres to the timelines specified in your insurance policy.
Why Choose Kantor & Kantor?
When you are up against a powerful insurance company that is delaying or denying your LTC claim, you need a law firm that not only understands the law but truly cares about you.
At Kantor & Kantor, we are people helping people, and we understand the challenges that come with fighting for your insurance benefits. Here is why you should choose us to represent you:
- Specialized Experience: Long-term care insurance is a niche field, requiring specific knowledge and experience. Our team focuses on this area, equipped with the insights and strategies that come from years of handling these specific cases. We know the laws, we understand the policies, and we recognize the tactics insurers use to deny claims.
- Client-Centered Approach: We believe in a personalized approach to legal representation. Each client’s situation is unique, and the strategy to address it should be as well. We take the time to understand your specific circumstances and tailor our services to meet your needs. Our goal is to make the legal process as clear and comfortable for you as possible.
- Proven Track Record: Results matter, and our track record speaks for itself. We have successfully helped many clients secure the LTC benefits they paid for and deserve. Our success stories range from overturning denied claims to negotiating favorable settlements, and even taking insurers to court when necessary.
- We Are Not Afraid to Take Insurance Companies to Court: Many law firms try to settle cases quickly and avoid litigation, but if your insurance company refuses to do the right thing, we are prepared to take them to court. We have the experience and resources to see your case through to the end.
- We Treat Our Clients Like Family: We take the time to listen to your concerns, explain your options, and guide you through the legal process. We do not believe in giving clients false hope, but we do believe in fighting hard for what is right.
How We Can Help with Your Case
Our experienced Tacoma LTC insurance lawyers have the knowledge and expertise to provide comprehensive support and representation, ensuring you receive the benefits you deserve. Here is how we can assist you:
- 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.
- Claim Filing Assistance: Filing an 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.
- Appealing Denied Claims: Insurance companies may deny claims for different reasons, often leaving policyholders feeling helpless. If your claim has been denied, our Tacoma 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.
- 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.
- 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.
- 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 Tacoma Long-Term Care Insurance Attorneys
We believe that people who have spent their lives planning for their future should not be left in the dark when they need care the most. You deserve dignity, respect, and the coverage you paid for.
Our team has years of experience going up against insurance companies that unfairly deny or delay claims. We know their tactics, and, more importantly, we know how to fight back. Whether your claim has been denied, delayed, or undervalued, we are here to make things right.
If you are struggling with a long-term care insurance issue, contact us at 818-886-2525 for a free consultation. Let us talk about your situation, explore your options, and take the first step toward securing your benefits. You do not have to do this alone—we are here to fight for you.
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]
