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. 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 receiving payment is a different story. This 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 have the ability to fight a claim denial. Many people purchased LTC policies long-ago and paid premiums for 20-years or more. Now when it is time to collect benefits, certain insurance companies 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.
Insurance Company May
- 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.”
- 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.
Understanding Your Policy Is a Must
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. 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.
Learn What Determines Eligibility
- Is it memory loss?
- 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.
To learn about all the legal options available to you and talk with a long term care claims attorney you can trust.