Denied long-term Care Insurance Claim

According to the Association for Long-Term Care Insurance (ALTCI), 273,000 Americans received approximately $7.5 billion in long-term care insurance benefits payments in 2013, which was 13% higher than in 2012. Since then, long-term care insurance claim payments have continued to rise steadily.  Despite this massive outlay of long-term care insurance benefit payments, many long-term care insurance policyholders still face potential claim denials. If you or your loved one is facing a long-term care insurance denial, then call attorney Steven M. Dunn today.

An Old Man Resting His Head On His Hands

Some of the Most Common Issues Surrounding Long-Term Care Insurance

The cost for long-term care services in America is on the rise. According to the Genworth 2013 Cost of Care report, the average cost of an assisted living facility was $41,400 a year, and a private room in a nursing home was about $83,950 per year. Hiring a licensed home health care aid can cost around $20.00 per hour. Since then, these costs have continued to rise exponentially. These rising costs can and do put a massive financial strain on millions of American families. For long-term care insurance policyholders, most of these costs should be covered by your insurance policy. However, if your long-term care insurance claim has been denied, the out-of-pocket costs can build quickly.  If you’re facing a long-term care insurance claim denial, then attorney Steven M. Dunn is here to help you. The long-term care insurance policy is complicated and mistakes can be costly. A long-term care insurance attorney can help you navigate this process.

Long-term care insurance is very nuanced and the policies are complex. The long-term care insurance industry is also highly regulated. Therefore, it is imperative that an insured understand their policy and understands the effect the law has on the policy. This complexity and the ever-changing law surrounding long-term care insurance often leads to claim denials. Below are some common reasons for long-term care insurance denials.

The Prior Confinement Provision

The prior confinement provision is a provision that appears in many of the older generation long-term care insurance policies. The provision acts as an additional barrier that must be passed before benefits will be paid. A typical prior confinement provision will require that for benefits to be paid, an insured must have had prior hospitalization confinement or a nursing home stay. What many policyholders do not know is that many states have prohibited such provisions. In some cases, a prior confinement provision can be found to be enforceable. Policyholders must seek out expert assistance when dealing with a policy that contains such a provision.

Insufficient Evidence or Documentation

One of the most common reasons a long-term care insurance claim is denied is insufficient evidence or documentation. Insurance companies are entitled to adequate records and documentation for them to determine claim eligibility. Poor or insufficient records will result in a claim denial. For a claim to be approved, the insured must make sure that they have provided enough strong supporting evidence to prove claim eligibility. A long-term care insurance attorney will assist you in submitting the strongest possible claim documentation.

Personal Care Service Alone Is Not Covered

Many insureds do not fully understand what types of services are considered covered services under their policy. This misunderstanding can and does result in claim denials. Many insureds will submit a claim based on their need for assistance with daily errands like cooking, cleaning, grocery shopping, and transportation. While some policies will pay for these types of services, they will only do so if the insured is also receiving assistance with their activities of daily living listed in their policy. Submitting a claim for personal care services without proof of daily living assistance as well will result in a denial.

The Benefit Eligibility Assessment

There are instances where an insured is on a claim and over time, their health has improved. Aware of this fact, insurance companies will periodically reassess insureds to determine whether they are still eligible for benefits under their policy. The biggest issue with these assessments is that the insureds may not be fully aware of the implications of that assessment. Many insureds do not understand how their policies work and therefore do not understand how their answers can be used as a basis to deny their claim. In addition, many insureds are proud people and will oftentimes understate their health issues to the assessor. The result is that it appears as though the insured no longer requires assistance and the claim is denied. Understanding these assessments is critical. A long-term care insurance attorney can assist in explaining the proper purpose of these assessments.

Lapses in Premium Payments

An unintentional policy lapse is the most preventable reason for a claim denial. Despite this, policy lapses still occur quite frequently. An accidental policy lapse usually occurs when an insured suffers from a cognitive impairment or a sudden health crisis. As a result of either the cognitive impairment, sudden health crisis, or both, the insured can no longer manage their financial affairs. This results in missed premium payments and eventually a lapse. One way to avoid a potential lapse is to name a third-party addressee. By naming a third-party addressee, the insured gains an extra layer of protection against unintended lapse. The third-party addressee will be notified of any gaps in premium payments and will hopefully take action to prevent a lapse.

Unfortunately, many insureds do not take advantage of this option. Due to the serious and potentially devastating nature of an unintentional policy lapse, the legislatures of many states have enacted laws to protect vulnerable seniors. The laws vary from state to state and can be technical in nature. The laws dictate that an insurance company must meet certain requirements before it can lapse a policy. Failure to meet these requirements may afford the insured the opportunity to reinstate their coverage. If you or your loved one has had their policy lapse, please seek out a long-term care insurance attorney as soon as possible. In instances of an unintentionally lapsed policy, time is of the essence, and failure to act quickly can reduce the chances of obtaining a policy reinstatement.

Steps To Take If Your LTC Claim Has Been Denied

A long-term care insurance denial can be significantly distressing for family members and loved ones, but there are some things you can do when you receive a long-term care insurance denial.

Learn The Reason For The Denial

The first step is to gather the relevant information and understand the basis for your denial.

If an insurance company has denied your claim for long-term care insurance benefits, they must provide you with information as to why the claim was denied. Our legal team can help walk you through the reasons for your denial and assist in rectifying the issues.

Request An Appeal

After you have ascertained the reasons for the initial denial, the next step is to seek out an appeal. Your long-term care insurance company will inform you about how their appeals process works. Each insurance company has its own time limit and technical requirements for the appeal process. The failure to meet these requirements can result in the claim being closed. The biggest issue with appeals is that oftentimes insureds will fail to address the reasons the claim was denied in the first place. This will result in an unsuccessful appeal.

This process may be overwhelming for many policyholders and their families. One of our attorneys can assist you through the appeals process and help ensure that the appeal is successful.

Schedule A Consultation With A Long-term Care Insurance Claim Attorney

long-term care insurance contracts are complex. The requirements for receiving benefits are nuanced and can be difficult to understand. There are also entire bodies of law dedicated to the regulation of long-term care insurance that must be considered. All these factors make understanding long-term care insurance difficult. However, misunderstanding your policy provisions can result in a costly crisis for insureds and their families. Call to schedule a consultation with one of our compassionate attorneys with years of experience dealing with long-term care insurance companies.

Why You Need a Long-term Care Insurance Claim Attorney

Long-Term Care Insurance attorney Steven M. Dunn has been an attorney for over three decades. He has been assisting seniors and their families with their long-term care insurance disputes for the last 16 years.

Throughout that time, our firm has dealt with every type of long-term care insurance issue out there. A long-term care insurance denial places a significant emotional, financial, and physical burden on insureds and their families. Insureds looking to utilize their policies are at their most vulnerable, and denials can be catastrophic.

A long-term care insurance attorney can guide you through the claims process, assist in overturning claim denials or work to reinstate lapsed policies. They can and will deal with your insurance company on your behalf, allowing you to focus on what’s important, which is getting the best possible care available.

Frequently Asked Questions

Long-term care insurance attorney Steven M. Dunn offers free initial consultations for policyholders with potential long-term care insurance disputes. You can call to schedule your consultation and read more below to learn more about long-term care insurance.

What are some of the top reasons for needing long-term care?

While 21% of recipients of long-term care insurance benefits need them due to being injured in an accident, the majority of recipients meet the long-term care insurance eligibility requirements by becoming older and meeting criteria through their disability or cognitive impairment. More Americans are living until their 80s and 90s, so a long-term care insurance denial can have a devastating impact on their ability to age with dignity.

How does a person meet long-term care insurance eligibility requirements?

There are two primary ways an insured can qualify for benefits under their long-term care insurance policy. The first way to qualify for benefits under a long-term care insurance policy is if the insured has a functional health issue that necessitates receiving assistance with their daily living activities. Typically, long-term care insurance policies will require that an insured need and receive assistance with at least two of their activities of daily living. In most policies, the activities of daily living are feeding, bathing, dressing, toileting, and transferring. If an insured requires assistance with two or more of the above-mentioned activities of daily living, then they are eligible for benefits under their policy. There is a lot of nuance surrounding this trigger. An insured must be aware of what constitutes “assistance” under their policy. Some policies require hands-on assistance, while others consider stand-by assistance to be sufficient. An insured-specific policy will dictate which level of care applies.

The second way to qualify for benefits under a long-term care insurance policy is via the cognitive impairment trigger. Suppose an insured is suffering from cognitive impairment to the extent that they are at risk of harm to themselves or others. In that case, they are eligible for benefits under the policy. Cognitive impairment can affect the following areas of cognition;

  • Memory
  • Reasoning and thinking
  • Learning
  • Awareness
  • Recognition
  • Concentration
  • Planning skills
  • Decision-making
  • Problem-solving

A claim under the cognitive impairment trigger will require submitting objective clinical evidence to the insurance company, proving the presence and degree of the impairment.

Are insurers allowed to cancel a long-term care insurance policy?

Long-term care insurance policies are guaranteed renewable. This means that a long-term care insurance company cannot cancel coverage for any reason except for non-payment of the premium. However, as discussed above, there are instances where non-payment of premium will not automatically terminate coverage. As explained above, if the insured is suffering from cognitive impairment or a functional health crisis that results in them unintentionally missing premium payments, you may be able to have your policy reinstated.

Call Steven M. Dunn if you or your loved one’s long-term care insurance policy has lapsed due to an unintentionally missed premium payment.