Jane Smith saved diligently for her retirement. In her late 50s, Jane purchased a long-term care insurance policy to avoid burdening her children in her later years. Some 30-years later, Jane could not live independently. With the counsel of her children and family physician Jane sold her home and moved into an Assisted Living Facility in the same town where she had lived for the past 50 years. After paying long-term care insurance premiums for 30 years it was now time for her to collect the benefits she deserved. Her children helped her file a claim with the long-term care insurance company. Jane qualified because she needed assistance with two Activities of Daily Living. The insurance company denied her claim and informed Jane that the insurance contract was a “home care” only policy and did not cover the cost of care in an Assisted Living Facility. Her children were furious and fought back. They hired an experienced attorney to contest the unfair insurance company tactics. Eventually with the assistance of an attorney the insurance company changed its position and paid Jane’s claim. Fortunately, their attorney understood that under certain state laws an Assisted Living Facility is a person’s home. This is not universal. All long term-care insurance policies are not the same. All state laws are not the same when it comes to licensing Assisted Living Facilities. Read your policy and seek help from a knowledgeable professional.
Long-term care insurance is one of the most valuable assets you can purchase. It can help cover the significant costs associated with in-home or facility-based care. As an experienced Long Term Care Insurance (LTC) Claims attorney, I understand that a denial from an insurance company is the beginning, not the end. LTC policies appear simple at first glance, but confusing at the same time, and receiving the benefit payments that you deserve sometimes is challenging.
This LTC insurance claims can be time-consuming and frustrating because insurance companies may place roadblocks in your way. To make matters worse, the very individuals seeking long term care too often don’t rarely have the ability to fight a claim denial. Many people of them purchased their LTC policies long ago and paid premiums for decades 20-years or more. Now when it is time to collect benefits, certain insurance companies sometimes make receiving payment difficult. An attorney who understands LTC policies and the methods that insurance companies use to evaluate claims can help you or your family get paid.
If you have questions about your long term care claim, contact Jonathan M. Feigenbaum, Esq. today.
Common Tactics Long Term Care Insurance Company May Use:
Insurance companies tend to lose money on long term care claims. Even though your premiums may have skyrocketed over the years, the cost of professional long term care has also increased. The average cost of a private room in a Massachusetts nursing home in 2017 was almost $150,000. In 2013 alone, long term care insurance companies paid out $7.5 billion in benefits. To cut costs, insurance companies don’t pay all the claims that they should.
The insurance company might use the following tactics in your long term care claims:
- Fail to advise you about all of the benefits within your insurance policy.
- Add terms to the LTC policy to disqualify an Assisted Living Facility by requiring on-site registered nursing 24-hours a day.
- Interpret LTC policy terms in such a narrow fashion not taking into consideration the proliferation of Assisted Living Facilities.
- Call your current residence, whether your home or a facility as an “ineligible provider.”
- Assert that you haven’t met the policy’s exclusion or waiting period
- Argue that you are capable of performing your “activities of daily living”
- Dispute the severity of your medical conditions
- Claim that your medical conditions fall within one of the policy’s exceptions, which might include substance abuse, war, and self-harm.
- Deny all long term care claims when an insured resides in a facility that is not “licensed” even though the insurance company knows that the particular state does not license any facility similar to where the insured lives.
- Deny receiving important documents from you.
- Use biased file reviewing doctors and nurses to justify a claim denial without even talking to you or examining you.
- Fail to explain to you in writing why the claim had been denied.
- Fail to explain to you in writing what information they need to process your claim.
- Not treat the policyholder as a person and instead treat the policyholder as an adversary.
- Delay, delay and deny claims that should be paid promptly.
You can fight back. An experienced long term care claims attorney understands the insurance company’s tactics and has built strategies that can counter them. When I work with clients, I carefully investigate the long term care claims and guide them through the sometimes overwhelming application and appeals processes. I know how difficult it is to transition to long term care. I try to take the additional burden of insurance claims off of our clients and let them focus on their health.
Understanding Your Policy Is a Must
When an experienced lawyer handles long term care claims, the first thing the attorney does is review the insurance policy. This document outlines all of the terms, conditions, exclusions, and procedures associated with a long term care claim. If you don’t understand and follow the policy’s requirements, you might lose your long term care benefits.
You should carefully examine your policy to understand the benefits provided. If you don’t have a copy, request it from your insurance company or employer (for group policies). This is because all policies are not identical. Some have more restrictive coverage than others — and many of the policies contain complicated loopholes, exceptions, and exclusions. Policies sold in the late 1980s and early 1990s are often the most generous in terms of coverage. Some state regulators carefully controlled the sale of LTC policies. Other state regulators failed on the job. Some policies have been enhanced through subsequent legislation, regulation and court decisions.
If you’re having a hard time interpreting your policy, contact a lawyer that frequently handles long term care claims. Jonathan M. Feigenbaum has fought for our clients’ long term care benefits for more than 25 years. I have built a reputation for skilled and compassionate representation. For a free claim analysis, contact us today.
Learn What Determines Long Term Care Eligibility
When you’re applying for benefits, medical evidence and information are essential to your long term care claims. Once you understand your policy’s eligibility requirements, you and your LTC lawyer will need to outline your eligibility and consider all of your medical conditions and limitations. Your eligibility might be caused by many factors.
- Is it cognitive difficulties caused by memory loss or dementia?
- Is it a medical determination that the insured is a danger to himself or others?
- Or is it inability to perform two or more Activities of Daily Living without “hands on” or “stand by” (within an arm’s length) assistance?
- Or something else?
I will take away some of the worry and fear in dealing with a claim denial and negotiate with insurance companies on your behalf. I will file suit when necessary and litigate your case to judgment.
When I handle long term care claims, my goal is to remove some of the worries and fear your family is facing. I have extensive experience interpreting insurance policies, medical records and expert testimony. Based on the facts and law, I negotiate with insurance companies — but I am not afraid to file a lawsuit and fully litigate my clients’ long term care claims when necessary. I am proud to serve our medically fragile clients and their families and help them stand up for what’s right.
To learn about all the legal options available to you and talk with a long term care claims attorney you can trust. For a free claim evaluation, contact the office of Jonathan M. Feigenbaum, Esq. today.
Assess Your Long Term Care Options
As we discussed above, not every long term care policy is the same. Some cover a wide array of care options, including in-home care and assisted living. Others only cover intensive nursing care. While today’s nursing care options have evolved to better reflect our modern values and preference for independence, many long term care policies did not change. This can cause confusion and delays when you make long term care claims.
Sometimes, insurance companies deny long term care claims because the care is allegedly insufficient, or the care providers lack services or qualifications required under your policy. For example, the insurance company might refuse to pay a family member for caregiving or deny a claim for housekeeping or home health aide services. While some policies clearly exclude these care options, others are more generous. However, some insurers are more concerned with their profits than your needs and will even try to add requirements that aren’t included in the policy language!
When I handle long term care claims, I help our clients understand their coverage and care options. This involves reviewing policy documents and comparing their terms and conditions with our clients’ care provider’s offerings. Once I have a clear understanding of their claim and circumstances, I explain legal options to you in plain English and demand fair treatment from the insurance company.
Contact a Long Term Care Claims Attorney in Boston Today
The law office of Jonathan M. Feigenbaum assists Massachusetts families with their long term care claims and other disability-related issues. We provide compassionate service, practical advice, and aggressive representation. Contact me to assist you in fighting your long term care claims.