- 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.
New England 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.
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.