In One Free Call We Will
  • Review your Long Term Care Claim
  • Assess your Long Term Care Policy & the Benefits Coverage
  • Help you navigate insurance company roadblocks
  • Provide legal advice to help you receive the Long Term Care Insurance benefits you paid for and deserve.

Dos & Don’ts

Long Term Care Claim

  • Review a copy of your policy.
  • Be sure that your physician established “Plan of Care” is consistent with the type of care that is covered under your policy.
  • Include appropriate certification by your physician. Do all of your communication with the insurance company in writing.
  • Obtain the name of the person to whom you are speaking and confirm the conversation with follow up correspondence, if you communicate with the insurance company orally.
  • Send correspondence by mail that can be tracked.
  • Give up, because the insurance company tells you that the facility is not licensed.
  • Overlook alternative care provisions.
  • Allow an insurance company assessment without a family member or knowledgeable caregiver present.
  • Let the claim forms impede the need to explain to the insurance company why you qualify for coverage.

Long-term care insurance is one of the most valuable assets you can purchase. LTC policies appear simple at first glance but getting paid is a different story.

Long term care insurance claims attorney Jonathan M. Feigenbaum, Esquire can help you file a claim, as well as appeal a denial. We understand that a denial from an insurance company is just a beginning and not the end. This can be time-consuming and frustrating because insurance companies may place roadblocks in your way.

Boston Long Term Care Claim Denied Insurance Claims Attorney

Long Term Care Law Firm

Long Term Care (LTC) Insurance is a type of insurance that companies like to sell and sometimes do not like to pay. Many LTC policies sold in the 1980s and 1990s were priced too low. The pattern follows Individual Disability Insurance sold between the mid-1980s and mid-1990s that insurance companies sold too cheap. Only years later when many more claims roll-in than the number the insurance actuaries predicted does the pricing issue become front and center.

Download our Long Term Care Insurance Fact Sheet: Long-Term-Care-Claim-Denied.pdf

We Can Help If Your Long Term Care Claim Has Been Denied

We can help ensure that people get the insurance benefits they deserve. Generally, we work on a contingency fee basis. That means you do not pay for our services on an hourly basis. We don’t receive compensation unless you win. Not every claim fits this mold, but most do. Let us take a look at your LTC policy without charge to you.

Filing a Long-Term-Care Insurance Claim

Long-term-care insurance policies (LTC) cover some of the costs of nursing and home health care, or assisted living facility needs if you or loved are unable to do Activities of Daily Living. While most people assume that Medicare and Medicaid will cover their nursing care needs, or home health care needs, or alternative living facility needs, these programs don’t always pay the full bill. And the government has strict spend-down requirements, which might require you to deplete your savings and assets.

For these reasons, many financial planners suggest LTC insurance as part of an estate or end-of-life plan. Below, Jonathan M. Feigenbaum, Esquire explains the four-step process of filing a claim for LTC benefits.

Step 1: Carefully Review the LTC Policy’s Terms

Long-term-care policies differ dramatically. If you discover that your loved one has LTC insurance, you should review the policy before you file a claim. While some policies cover any type of facility, including in-home care and assisted living, others will only pay for services at a nursing home.

You’ll also want to see if the LTC policy has a waiting or “elimination” period. During this time (which is can be up to 100 days), the patient must pay for all of his or her care out-of-pocket.

You can request a copy of the LTC policy from your agent or the insurance company. However, some of these policies use highly technical language and are difficult to interpret. If you need help understanding the terms and conditions of a long-term-care policy, contact an experienced insurance benefits attorney.

Step 2: Understand the Policy’s Benefit Trigger

Most, if not all, long term care plans have a “benefit trigger,” or a set of eligibility requirements. They typically involve your ability to care for yourself. When you file a claim, the insurance company will assess your (or your loved one’s) ability to independently engage in Activities of Daily Living:

  • Perform personal hygiene activities (such as showering, bathing, and brushing teeth)
  • Dress yourself
  • Use the toilet
  • Eat and prepare meals
  • Ambulate — safely move around
  • Cognitive impairment — make good decisions and think clearly and not endanger yourself

Sometimes if you cannot do 2 or 3 of the above Activities of Daily Living, you might qualify for long term care benefits. And you can always consult with treating physicians and a skilled insurance benefit lawyer if you need help assessing you or a loved one’s eligibility.

Step 3: File Your Claim and Participate in the Claim Investigation

Once you understand the policy’s requirements and assess your eligibility, you can file a claim with the long- term-care insurance company. This might involve the following:

  • Completing a series of forms
  • Participating in an initial phone assessment
  • Meeting face-to-face with an insurance adjuster
  • Submitting medical records from your doctors and the nursing facility
  • Getting a statement from your treating physician
  • Proposing a long-term care plan
  • Providing other information that helps explain why you qualify

This process can seem overwhelming when you’re dealing with serious medical issues. While you should consider having a family member coordinate your application (and have a durable power of attorney), a skilled insurance benefit lawyer can assist in the process so that you properly complete the application process and present a compelling case why you should get paid the benefits you paid for and deserve.

Remember, long-term-care insurance companies are for-profit businesses. They look for reasons to deny claims and save money — especially if the claim involves intensive and prolonged medical treatment. Many LTC policies were priced too low and have resulted in losses to insurance companies.

Step 4: Receive Benefits or File an Appeal

Once the insurance company completes its investigation, it will either approve or deny your claim. If it approves your claim, it typically will reimburse you for long term care expenses. If it denies your application, you have the right to appeal. However, long-term-care insurance policies typically have strict appeal deadlines and processes. Before you initiate an appeal, you should always consult with a lawyer.

Why Do Insurance Companies Deny Claims?

Assumptions regarding the lapse rates of long term care insurance, the number of persons who would pay for policies for a few years, and then stop, were wrong. The loss ratio, the receipt of premiums plus investment income, compared with the dollar amount of claims paid, has been far greater than anticipated for some insurance companies. In other words for every $1 the insurance company receives, it may be paying out $2 in claims. As a result, insurance companies that did not price the policies adequately have a tendency to deny many claims.

Requesting payment for claims is difficult, frustrating and time consuming. Too often people who need these insurance benefits don’t have the energy or mental faculties to fight with the LTC insurance company. Children of elderly parents may not live close by and cannot readily help their parents get the LTC benefits that they paid for long ago.

Understanding What Costs Long Term Care Insurance Helps to Cover

Many people do not realize that Medicare does not typically cover long term care. Unless an elderly or disabled loved ones qualify for Medicaid, they may be financially responsible for their nursing home expenses. Long term care insurance helps cover costs related to:

  • Nursing homes,
  • Home health care (such as the services of a home health aide),
  • Respite care (care that allows a family caregiver to take a break),
  • Adult day care facilities, and
  • Other services related to the care of an elderly or disabled loved one.

As baby boomers have aged, many have looked to long term care insurance as a way to protect their financial interests.

Unfortunately, many long term care claims are denied. As discussed above, many policies were underpriced. Since the cost of most long term care is very high (according to a 2016 survey, the average private nursing home room in Massachusetts costs $12,015 per year), there is a financial incentive for insurance companies to deny these underpriced policies.

Interpreting the Fine Print of LTC Insurance Policies

The “fine print” in LTC insurance or interpretation of ambiguous language may allow an insurance company to deny benefits. Often insurance companies will not pay for claims relating to an Assisted Living Facility. Many insurance companies argue improper licensure of the facility in order to deny a claim. In fact, not all states license every type of facility that insured individuals typically expect LTC insurance to pay for.

A long term care policy is a contract between you and the insurance company. The company will cover certain expenses as long as you meet the terms and conditions set out in the policy. Unfortunately, the “fine print” in these policies can be very technical and difficult to understand without the help of a lawyer. Many policies contain:

  • Waiting periods before you are eligible for coverage,
  • Limitations on what types of services are covered,
  • Specific claim and appeals processes, and
  • Strict filing deadlines.

Even one mistake can result in a denial of long term care coverage.

Other times, the “fine print” is overly vague. Ambiguous policy language can lead to disputes. For example, suppose a long term care policy covers care at an “approved facility,” but does specifically define that term. You assume that an “approved facility” is a state-licensed assisted living center. However, when you file a claim, the insurance company denies it, claiming that an “approved facility” must meet other strict criteria that are not included in the policy.

Schedule a No-Risk Consultation With an Experienced Attorney Knowledgeable in Long-Term-Care Products

Jonathan M. Feigenbaum, Esquire assists families nationwide with long-term-care insurance applications and appeals and litigation. He is a respected disability insurance advocate with extensive experience handling claims for long-term-care insurance, disability payments, health benefits, and life insurance. You can schedule a free, no-risk consultation by calling his office or completing a simple, online form.

Why Insurance Companies Deny Claims

Assumptions regarding the lapse rates of long term care insurance, the number of persons who would pay for policies for a few years, and then stop, were wrong. The loss ratio, the receipt of premiums plus investment income, compared with the dollar amount of claims paid, has been far greater than anticipated for some insurance companies. In other words for every $1 the insurance company receives, it may be paying out $2 in claims. As a result, insurance companies that did not price the policies adequately have a tendency to deny many claims.

Requesting payment for claims is difficult, frustrating and time consuming. Too often people who need these insurance benefits don’t have the energy or mental faculties to fight with the LTC insurance company. Children of elderly parents may not live close by and cannot readily help their parents get the LTC benefits that they paid for long ago.

What Is Long Term Care Insurance?

Many people do not realize that Medicare does not typically cover long term care. Unless an elderly or disabled loved ones qualify for Medicaid, they may be financially responsible for their nursing home expenses. Long term care insurance helps cover costs related to:

  • Nursing homes,
  • Home health care (such as the services of a home health aide),
  • Respite care (care that allows a family caregiver to take a break),
  • Adult day care facilities, and
  • Other services related to the care of an elderly or disabled loved one.

As baby boomers have aged, many have looked to long term care insurance as a way to protect their financial interests.

Unfortunately, many long term care claims are denied. As discussed above, many policies were underpriced. Since the cost of most long term care is very high (according to a 2016 survey, the average private nursing home room in Massachusetts costs $12,015 per year), there is a financial incentive for insurance companies to deny these underpriced policies.

Interpreting the Fine Print

The “fine print” in LTC insurance or interpretation of ambiguous language  may allow an insurance company to deny benefits. Often insurance companies will not pay for claims relating to an Assisted Living Facility. Many insurance companies argue improper licensure of the facility in order to deny a claim. In fact, not all states license every type of facility that insured individuals typically expect LTC insurance to pay for.

A long term care policy is a contract between you and the insurance company. The company will cover certain expenses as long as you meet the terms and conditions set out in the policy. Unfortunately, the “fine print” in these policies can be very technical and difficult to understand without the help of a lawyer. Many policies contain:

  • Waiting periods before you are eligible for coverage,
  • Limitations on what types of services are covered,
  • Specific claim and appeals processes, and
  • Strict filing deadlines.

Even one mistake can result in a denial of long term care coverage.

Other times, the “fine print” is overly vague. Ambiguous policy language can lead to disputes. For example, suppose a long term care policy covers care at an  “approved facility,” but does specifically define that term. You assume that an “approved facility” is a state-licensed assisted living center. However, when you file a claim, the insurance company denies it, claiming that an “approved facility” must meet other strict criteria that are not included in the policy.

Get Help From an Insurance Claims Attorney

We can help you or your elderly family member in need of assistance. We ensure that people get the insurance benefits they deserve. Generally, we work on a contingency fee basis. That means you do not pay for our services on an hourly basis. We don’t receive compensation unless you win. Not every claim fits this mold, but most do. Let us take a look at your LTC policy without charge to you.

Contact an insurance claims attorney today for a consultation. Call us at 617-357-9700 or fill out our How Can We Help form for A COMPLIMENTARY CONSULTATION.

Learn everything you need to know with this helpful Long Term Care Insurance fact sheet.

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