Long-Term Care Insurance
Long Term Care Insurance Claim Denials & Policy Cancellations
We Will Fight for You if Your Long Term Care Insurance Claim Was Denied or Your Policy Cancelled by an Insurance Company
If the insurance company has denied you or your loved one’s claim or cancelled the insurance policy, do not assume that the decision is correct. It is critically important to have the insurance company’s actions reviewed by a long term care insurance attorney.
What Does Long Term Care Insurance Cover?
Long Term Care Insurance is often purchased decades before the coverage will be utilized as the coverage typically doesn’t become necessary until an individual ages. In other instances, however, an individual may suffer from an unexpected illness in which they are unable to meet their self-care needs at an earlier age.
Long Term Care Insurance generally provides coverage for elderly or chronically ill individuals who satisfy the following requirements.
- The insured’s inability to generally perform two or more of the following activities of daily living:
- The insured requires supervision for their own safety or the safety of others due to cognitive impairment that impacts:
What Benefits Does Long Term Care Insurance Provide?
Long Term Care Insurance typically pays a daily maximum rate that may range anywhere from $100.00 to $500.00 per day to cover costs related to:
- Residential Elderly Care Facilities
- Assisted Living Facilities
- Nursing Homes
- Home Health Care
- Adult Day Care Facilities
- Respite Care
- Hospice Care
Also, most policies provide for a lifetime maximum amount, which is the maximum amount that an insurance company will pay during the lifetime of an individual.
The Most Common Tactics Insurance Companies Use to Avoid Paying Long-Term Care Claims
For many insurance companies, the long-term care insurance block has not been profitable due to many factors, including underpricing coverage and underestimating their insureds’ life expectancy. As a result, insurance companies have been trying to make up for the difference by engaging in aggressive claims handling tactics.
Your insurance claim may be initially denied without the payment of any benefits or benefits may be terminated after the insurance company has paid benefits for months or even years.
Insurance companies use the following tactics to not pay long-term care insurance benefits:
Making it unreasonably difficult for you to submit your claim
- Failing to provide any meaningful assistance during the claims process
- Creating unreasonable obstacles through the requirement of unnecessary forms and information
- Enforcing strict deadlines
Claiming the medical support the insured has submitted is insufficient
- Discounting the opinions of the insured’s treating physicians
- Asserting that the physical assessment or plan of care is inadequate
- Relying on statements from employees at facilities who have inadequate information regarding the insured and the insured’s abilities
- Utilizing and exaggerating surveillance footage
Misapplying the terms of the Policy to deny coverage
- Claiming that the long-term care provider is ineligible
- Claiming that the facility is ineligible
Cancelling the insurance policy in violation of the terms of the policy
- Unintentional lapses of coverage due to nonpayment of premium due to cognitive issues or a health crises
- Failing to give the notice of the lapse as required under the Policy before cancelling the coverage
- Failing to give notice to the third party individual designated by the insured
Do Not Assume That the Insurance Company Properly Denied Your Claim or Cancelled Your Coverage
You should have the claim denial and/or cancellation of coverage reviewed by a Long-Term Care Attorney. Our caring and knowledgeable attorneys are here to assist you with your Long-Term Care Insurance needs.
What is a Waiver of Premium?Most long-term care policies provide for the waiver of premium once a claim has been made and eligibility for benefits confirmed by the insurance company. This means that premiums will not be owed during the time that you or your loved one is receiving benefits under the policy. Before discontinuing payments, please be sure to confirm with the insurance company that the premium is, in fact, waived once eligibility has been established.
What information is required to submit a Long-Term Care Claim?
The insurance company should provide forms and notify you of other information necessary to submit a claim. Such forms and information include the following:
- Policyholder Statement in which basic information is provided about you, the basis of your claim, and the care you have been receiving, if any.
- Attending Physician’s Statement in which your doctor describes why the care is needed. The doctor may also need to provide recent medical records.
- Assessment and Care Plan. This may be handled in a number of ways depending on the insurance company. The insurance company may require that the assessment be completed by the treating physician, a healthcare provider at the facility, or an individual selected by the insurance company to meet with you and conduct the assessment. Once the assessment is complete, the Care Plan will be developed, which directs the level of care required for the individual. If an individual’s claim is based on cognitive deficits, the assessment may require neuropsychological testing.
- Provider Statement to demonstrate that the provider is qualified to deliver the services necessary. The provider may need to supply copies of certifications or licenses. Many policies will not permit family members to be paid to provide care. It is crucial that someone who fully understands insurance policies reads and interprets the pertinent policy terms before a claim is made.
- Authorization to Release Information. This allows the insurance company to obtain pertinent medical records related to the physical or mental condition leading to the required care.
The Insurance Company will likely complete a telephone interview to review the information submitted as part of the claim. If the claim submission process is taking too long or the insurance company appears to be creating unnecessary and unreasonable hurdles to obtaining benefits, reach out to a long-term care insurance attorney to review the situation.
Who can provide Long-Term Care services?
There are many types of providers of personal care services, and those services may be provided in a number of different settings, as detailed below.
- At-home care. Some policies allow a family member to provide the care while other policies require a professional caregiver. The policy may provide the option for a family member to become a certified caregiver. There are numerous home health care agencies that have qualified individuals to provide the necessary care at home.
- Adult day care is non-residential care that provides planned social activities for individuals who require supervision during the day, perhaps, while a family member is working.
- Assisted living facilities provide housing, meals and planned social activities and offer various levels of care that are customized to the individual’s needs.
- Nursing home / skilled nursing facilities provide care for those individuals who require the highest level of self-care, which oftentimes includes medical care.
Is Long-Term Care Insurance a guaranteed renewable policy?Long-term care insurance is guaranteed renewable, which means it can only be cancelled if the premium has not been paid. However, before a policy can be cancelled due to non-payment of premium, the insurance company must comply with the notice provisions in the policy and those provisions must be clear and unmistakable.
Long-Term Care Insurance
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If you are facing a dispute for your Long-Term Care Insurance Claim, it is imperative to seek assistance from a knowledgeable insurance lawyer as soon as possible. Our experienced lawyers can guide you through the legal process, explain your options, and work to craft the strongest possible solution on your behalf.