Long-Term Care Insurance covers costs involved with personal or medical services that are needed for an individual who is unable to care for him or herself due to disability, chronic illness, loss of functional capacity, or cognitive impairment. Thus, the goal and reason for paying costly Long-Term Care Insurance premiums is to cover the expensive services involved in keeping a loved one as independent as possible in these situations.
Long-Term Care Insurance spend a great deal of time and money training their claims examiners and investigators to highly scrutinize every claim filed. An admission of liability by an insurance company for a Long-Term Care Insurance claim is a very costly move by the company given the expensive nature of long-term care. Navigating a Long-Term Care Insurance claim process can be complicated and frustrating for an individual dealing with an insurance company motivated to deny the claim, and many times the company will unfairly delay or deny the payment of the benefits. This can be financially and emotionally devastating for both the person requiring long-term care and also his or her family. A person’s financial and medical independence is at stake and the need for long-term care and the steep costs for this type of care does not go away if the insurance company denies the long-term care insurance claim.
Cancellation of Your Policy Due to Non-Payment of Premiums:
When the need arises for you to file for your long-term care benefits, or your loved one’s benefits, you may suddenly learn that premiums are outstanding and unpaid. One of the most common reasons is that the insured suffers from a condition such as Alzheimer’s or Dementia which affects his or her ability to remember to do things such as pay premiums. Or, the insured may have become too ill too quickly and was unable to keep up with bills, or the insured was forced to pay hospital bills instead of premiums. There are requirements under your policy and the law which require that the insurance company give you a certain period of time to become current with premium payments, and also require that a “third party designee” be notified of the missed premium payments. Thus, don’t trust that your insurance company is properly denying your claim for benefits due to missed premium payments or non-payment of premiums.
Misconstruing a Limitation under Your Policy and/or the Facts of Your Claim:
Long-Term Care Insurance companies commonly argue the following to delay or deny your Long-Term Care Insurance claim:
- You weren’t hospitalized prior to needing long-term care;
- You do not suffer from an acute medical condition;
- The long-term care services that were provided to you were not provided by a registered nurse, licensed practical nurse, or other properly qualified professional as defined under your policy;
- The care or services were provided to you by a family member;
- The long-term care services that were provided to you were not provided by a nursing home or home care provider that are certified by Medicare;
- The long-term care services provided for you are available under Medicare or another governmental program;
- The long-term care services that were provided to you are not covered “skilled care”;
- You are able to perform your “Activities of Daily Living”, which usually include bathing, dressing, walking, moving from bed to chair, toilet, maintaining continence, and eating;
- The care or services that you received are unrelated or unnecessary for you to carry out instrumental activities of daily living or unrelated to needs because of a cognitive impairment;
- The insurance company’s doctor is saying that you do not qualify for long-term care benefits even though your doctor is stating that you do;
- The insurance company has denied certain types of long-term care provided, asserting that you did not need the level of care that you were provided;
- You have not provided sufficient ongoing verification of long-term care needs;
- You suffer from a pre-existing condition;
- Your medical condition is not covered because it is the result of one of the following: mental illness, attempted suicide or intentionally inflicted injury, alcoholism or drug addiction, war or acts of war;
- Your benefit amount is less than you understood it to be.
Long-Term Care Insurance policies are extremely complicated policies drafted by insurance company attorneys and likely include multiple loopholes that are advantageous to the insurance company. Furthermore, the types of coverage that a person can purchase greatly vary, as do the additional purchase options often called riders that add additional coverage under your policy. The types of services and/or devices that your policy covers, how your benefit is calculated, how and when your benefit is due to be paid, and types of medical conditions covered are just a few examples of how coverage can vary significantly from policy to policy. Thus, understanding the contents of your Long-Term Care Insurance policy and your rights under the law is critical when your insurance company is arguing that your claim is denied due to a limitation under the policy or is misconstruing the facts of your situation to deny benefits.
Insurance companies regularly delay payment of long-term care insurance benefits by simply continuing to request additional, duplicative and unnecessary information and documentation from you and your providers. The insurance company will assert that without this additional information, it is unable to approve your claim for insurance benefits. This can go on for months and even years if the insurance company is allowed by you to continue. The sad truth is the insurance company is employing a delay tactic called slow walking to avoid paying the claim. Many claimants may give up the fight against the insurance company who outnumbers them in resources because they are too disabled or sick, or they may even die before benefits are paid. It is very important to understand the difference between being cooperative and responsive to requests for information by your insurance company, and being subjected to slow walking which is allowing the insurance company to wrongfully delay payment of your benefits.
The insurance company is trained to have no empathy for an insured individual’s situation. At the end of the day, an insurance company is a business. They are worried more about their bottom line rather than the insurance coverage they promise. The more premiums that they accept, and the more claims they deny, the greater they will profit as a business. The insurance company trains its employees to treat people filing claims as a paper file, and not a person, and to deny claims for any arguable reason – the person filing an insurance claim is not to be trusted and is scrutinized as a fraud. Yet the reality is that no one wishes to deal with the unfortunate situation where they or their loved one requires long-term care. Instead, Individuals choose to pay a significant amount of money in premiums for these policies to protect themselves and their families in such unfortunate circumstances. When an insurance company accepts these premiums, it has an obligation under the law to pay legitimate claims for necessary long-term care benefits.
If you or a loved one has experienced a delay or denial of payment of your long-term insurance benefits, contact one of our experienced attorneys at www.dilawgroup.com.