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Long Term Care Insurance Denial Attorney

Did You or Your Loved One’s Long Term Care Application Get Denied?

If you or a loved one applied for Long Term Care insurance and were denied, we can help. Our long term care insurance lawyers fight against insurance companies for people who were wrongfully denied benefits. If your claim has been denied, we invite you to call our office at 888-583-4959 or fill out our online contact form to speak with an attorney and learn about your options. The call is free and there’s no obligation.

After years of paying premiums, people are stunned when their long term care claims are denied. In recent years, many companies have stopped selling Long Term Care Policy Insurance. Those who still sell long term care insurance only sell to people with extraordinarily good health, and who can afford the high premiums.

If you were smart enough to purchase a long-term care insurance policy years ago, before the insurance sector tightened up on selling policies, you may face an uphill battle when trying to make a claim.

This is a battle you don’t want to take on by yourself. With the Law Office of Justin Frankel, you don’t have to. We are experienced and aggressive long term care attorneys for insurance claim denials.

As more Americans need the care that only a long-term nursing facility can provide, they are finding out that the insurance companies they count on seem to be determined to pay as little as possible or not at all. The Law Office of Justin Frankel represents people just like you who paid premiums for decades to protect themselves and their savings from the exorbitant costs of long-term care.

elderly long term care patient assisted by doctor - The Law Offices Of Justin Frankel

Why Was My Long-Term Care Insurance Coverage Denied?

While there are many different tactics used by long-term care insurance companies to deny claims, the reason for the denials and delays are simple: profit.

When long-term care insurance policies were originally sold, the insurance companies’ actuaries and economists expected the policies to be profitable. Along the way, improvements in medical care and medicines extended the length of the average American’s lifespan. Medical care is costly, Americans are living longer and needing the care, and paying benefits on long-term care policies is problematic for the insurance companies. A large number of insurance companies actually sold their long-term care insurance divisions. Those who are left are doing everything they can to maximize their profits for shareholders. Your claim is their unwanted overhead.

Can You Fight Back on a Denied Long Term Care Claim?

You can fight back when a claim is denied, when the long term care insurance company is asking for an overwhelming amount of paperwork, or if the company seems to be delaying the claim to an unreasonable extent.

This is one fight you don’t want to take on by yourself. The long term care insurance companies have deep pockets, many law firms to represent them, and doctors and nurses on retainer to declare that you or a loved one do not qualify for care. You need an aggressive long term care attorney with experience in long term care insurance claim denials and the tenacity to fight back.

How Do You Prove Eligibility For Long Term Care?

Activities of Daily Living or ADL

There are six activities of daily living (ADL), and claimants need to be able to prove that they are medically unable to perform at least two of them.

  1. Bathing, including taking a shower, brushing teeth, and grooming unassisted
  2. Getting dressed and undressed
  3. Meal preparation and eating
  4. Toileting and continence – including control and hygiene
  5. Functional Transferring – walking to and from rooms in your home
  6. Getting in and out of bed safely

Typically, long term care insurance for nursing home costs requires that an individual be unable to perform two or more of the six ADLs. Coverage all depends upon the language in your policy and the insurance company’s determination of whether or not you are truly unable to care for yourself.

Common Reasons For a Long-term Care Claim to be Denied

Alleged Nonpayment of Long-Term Care Premiums

Every payment for a long-term care premium should be noted not just in your checkbook but documented to demonstrate proof of payment. A copy of a canceled check or an email confirming receipt of payment should be secured. In most states, claimants have up to five months before a policy lapse because of nonpayment.

There are instances where an elderly person might forget to pay a premium, but states have laws to protect consumers. Often, there is an option to have another person, usually an adult child, named as an alternate contact just in case a premium is missed because of illness or diminished capacity. A declaration of proof of cognitive decline from a physician may be enough to reinstate coverage, but some long-term care insurance companies are not so easily satisfied.

We can help you fight back. A call or a letter from a law firm always elicits a different response from an insurance company employee.

Proper Licensure of Facility as an “Eligible Care Provider”

A long-term care insurance policy is a contract between the claimant and the insurance company. Like many contracts, the long-term care policy is steeped in legalese and may be difficult for a layperson to understand. One of the provisions used to deny claims is the licensing status of the facility where long-term care is being provided.

It is extremely important to review the policy and be sure that the facility under consideration will be covered by the policy.

Very often, a patient cannot be sent directly home after receiving care in a hospital. They need to receive a certain level of care, medications, or therapies. When this occurs, families will often go to long-term care facilities and meet with the admissions staff to determine whether or not there is a bed available, if the kind of care the person needs is available at the facility, and if the facility accepts the long-term care insurance policy. There are instances when the hospital pressures the family to move the patient and the care facility also wants a fast decision. This is never good for the patient, especially if one of the family member’s takes the “We don’t care how much it costs” position—which sounds great, but doesn’t work out once the first invoice is received.

Be sure the facility meets the criteria set in the long-term care policy. It may have language that indicates broad coverage for nursing homes, limited coverage assisted living, or licensed home care with a properly licensed agency.

What if The Facility Is Not Properly Licensed?

The company running the nursing home or assisted living facility must prove to the long term insurance company that it is an “eligible care provider.” The licensing or criteria sometimes depends on having the appropriate staffing and specific services, along with the necessary state licensing. It seems like something you should be able to find out before moving into a facility, but very often the time between being discharged from the hospital into a nursing care facility with available beds is short and the facility that accepts your long-term care policy for coverage may not have the services needed.

Read the fine print. Some policies will pay for home health care, but only if the caregivers are licensed and work for a licensed agency. Even if you are paying for this yourself during the elimination period, the elimination period is also subject to qualifying factors.

No Prior Hospitalization

Over the years, terms and limitations in long-term care polices change. Factors that might have been acceptable to the long-term care insurance company ten years ago are no longer permitted. At the same time, older policies include provisions that haven’t seen the light of day in years. One of those is called the “gatekeeper” provision. It requires that before you can receive benefits on your long-term care insurance policy, you need to have had either a hospitalization, a nursing home stay, or, in the worst case scenario, both, before the insurance company will deem you eligible for coverage.

Conflicting Medical Opinions.

Here’s where Long-Term Care Insurance and Long-Term Disability Insurance are alike: denying coverage based on medical status. The long-term care insurance company has a doctor review medical records and determine, without even examining you, that you don’t meet the requirements for long-term care.

We know from long experience how flawed these paper reviews are. We also know that sometimes the insurance company’s doctor or nurse is only provided with a small part of your medical records. Or that you may have a complex issue and they have no background or specialized knowledge of your issue. It takes strong representation to overcome this denial, including knowledge and experience with medicine and the law.

There’s an inherent conflict of interest here. Is the same doctor or nurse who is being paid by the insurance company have the ability to be completely unbiased, when they know the insurance company’s preference is not to pay your claim? This is an issue we have encountered numerous times throughout our practice of insurance law. Even courts recognize this, and call it out when they see how overt it can be.

Benefits for Personal Care Not Part of Your Policy

Here’s where having an experienced long term care attorney can help. The insurance company says that the policy does not cover personal care, which typically includes light housekeeping or having someone who can run errands for you – going shopping, etc. But is that correct? Without being able to skillfully review the legalese in your contract, you may have this coverage after all.

Do You Have a Plan of Care?

A Plan of Care (or a Care Plan) is part of the requirements for most, if not all, long-term care claims. This is an assessment of your health condition, and must be completed at least every 90 days after the first time it is conducted. If it is not provided in a timely manner, the long-term care insurance company can stop paying benefits.

Long term Care patient assisted by female nurse - The Law Offices Of Justin Frankel

When Should You Seek A Long Term Care Attorney For Your Claim?

Some companies will begin paying benefits 60 days after you file a claim. Others count on “service days,” counting only the days you pay for home health care, for example. If you have a person coming to the house to help you three days a week, only those three days are counted as part of the waiting period. It will take 20 weeks before benefits kick in. In the meantime, you or your family must pay out-of-pocket.

As soon as there is a problem, file the claim. The insurance company will review the claim and may send a nurse or a social worker for an at home visit. We tell our clients they should never be alone in the home with any insurance company representative who comes for a home visit. A trusted family member, an adult child, or a responsible friend should be present. Any interaction with insurance company representatives of any kind should be documented and, if in person, witnessed by another person.

The treating physician must confirm in writing all of the details of the claimant’s disabilities, including a prescription for home health care seven days a week or nursing home care for life. The doctor’s report must reflect the kind of care that is needed.

Your representative should be the contact, not the patient, especially if they are infirm or suffering from Alzheimer’s. No one likes to admit how sick they are, and a dementia patient could have a brief moment of clarity that the insurance company representative characterizes as a reason not to receive benefits.

Why You Need a Long-Term Care Insurance Attorney

We can fight for your claim against any major insurance company nationwide. Please call our office at 888-583-4959  or fill out our online contact form to speak with a long term care attorney and learn about your options. The call is free and there’s no obligation.

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