1st in a Series on Long-Term Care (LTC)
As we grow older, many of us become acutely aware of the care needs and financial arrangements necessary for aging parents. Long-term care insurance (LTC) is designed to assist with the costs associated with various forms of assistance, including in-home care, assisted living, and nursing home facilities. Unfortunately, claim denials can hinder families from receiving the support they expect.
If your parents’ long-term care claim has been denied, understanding the reasons behind the denial and your parents’ legal rights is essential to take appropriate steps forward.
The Importance of Long-Term Care Insurance
Long-term care insurance is a safety net that protects families from the substantial costs associated with care services that are not typically covered by health insurance or Medicare. According to Genworth’s 2024 Cost of Care Survey, “The national annual median cost of a semi-private room in a nursing home rose to $111,325, an increase of 7%, while the cost of a private room in a nursing home increased 9% to $127,750.”
Types of long-term care can vary widely, from in-home assistance to more extensive skilled nursing care in a facility. Purchasing insurance early may yield lower premiums and guarantee coverage for necessary services in the future. For many families, long-term care insurance provides peace of mind, knowing they can secure necessary resources without depleting savings or assets.
Common Reasons for Claim Denials
Even with a long-term care policy in place, claims can still be denied for various reasons. Understanding these reasons can provide insight into whether the claim denial is valid or if there are grounds for appeal. Some common causes for denial include:
- Non-Covered Services: Insurance policies often specify covered services. If your parents are seeking services that fall outside this scope or were not outlined in the policy, the claim may be denied.
- Failure to Meet Eligibility Requirements: Long-term care policies generally have specific eligibility criteria related to the type and duration of care needed. If your parents do not meet these requirements, such as needing assistance with a minimum number of activities of daily living (ADLs) over a defined period, the claim may be denied.
- Insufficient Documentation: Insurers require thorough documentation to support a claim. If your parents did not provide adequate medical records, assessment reports, or proof of the necessity for care, the claim may be rejected.
- Policy Exclusions: Many long-term care insurance policies include exclusions for pre-existing conditions or other specific limitations. If your parents’ health issues are considered pre-existing or if they fall into an exclusion category, this could invalidate the claim.
- Failure to Pay Premiums: If premium payments lapse, the policy may become void. A claim will be denied if the policy is not currently active due to non-payment.
Understanding Your Parents’ Legal Rights
When a long-term care insurance claim is denied, it can feel disheartening, but your parents hold specific legal rights that can assist in navigating the appeal process. Here are several important rights they possess:
- Right to Appeal: Once a claim is denied, policyholders have the right to appeal the decision. Insurers are required to provide a formal explanation regarding the denial, and policyholders can ask for a review of the decision, often involving additional documentation or evidence.
- Right to Review Documentation: Your parents can request copies of all documentation related to their claim, including the insurance policy and any records that the insurer used to justify their denial.
- Right to Legal Representation: If the appeal fails, your parents have the right to seek the assistance of an attorney experienced in long-term care insurance disputes. Legal counsel can ensure that their rights are safeguarded and that they have the best chance at a successful appeal or litigation if necessary.
- Right to External Review: In some states, if an insurer denies a claim and the appeal is unsuccessful, policyholders can request an external review by an independent third party to evaluate the claim.
- Right to Consider Additional Legal Action: If all avenues of appeal have been exhausted, your parents may have the right to pursue legal action against the insurance company if they believe the denial was unjust.
Frequently Asked Questions About Long-Term Care Insurance Claim Denials
Can I appeal a long-term care insurance claim denial?
Yes, policyholders have the right to appeal any claim denial by following the insurer’s appeals process. Make sure to gather all necessary documentation to support your case.
What should I do if I believe the claim was unjustly denied?
Gather your documentation, including the policy, medical records, and evidence of care needs. Then consult with an attorney knowledgeable in long-term care insurance claims to guide you.
Why is documentation so important for long-term care claims?
Insurers rely on thorough documentation to assess eligibility and validate the need for care. Inadequate or missing documentation can lead to denials.
How can I check if my parents’ policy covers their specific care needs?
Please carefully review the policy details to understand what services are included. If you are confused, consider contacting the insurer for clarification.
What if the insurance company continues to deny the claim after an appeal?
If the appeal is unsuccessful, your parents can consider seeking legal advice to explore further options, including potential legal action or requesting an external review, depending on state laws.
Help with Long-Term Care Claim Denials in CA, WA, OR, & NV
A long-term care claim denial can be frustrating, but recognizing the reasons for denials and being aware of your parents’ legal rights can empower you to take the necessary steps toward resolution.
If you find yourself in this situation, don’t hesitate to reach out for legal guidance to ensure that your family’s rights are protected and to help secure the care your parents deserve. Contact Kantor & Kantor, LLC, to schedule a confidential consultation.
