Did You or Your Loved One’s Long Term Care Application Get Denied?

If you or a loved one applied for coverage under a Long Term Care policy and were denied or if your claim for long term care benefits is not being decided in a timely manner, we can help. For two decades, we have fought back against insurance companies for people when their claims are either wrongfully denied or are being delayed.  If your claim for long term care is like this, call our office at (877) 406-7883 to speak with an attorney and learn about your options. The call is free and there is no obligation or cost to do so. 

Long term care insurance is incredibly expensive, and yet when needed most, it often appears worthless.  Care that should trigger this coverage is also incredibly expensive, and often can ruin a family financially.  Securing your long term care insurance benefits is crucial.  

People are stunned when their long term care claims are denied, naively believing that paying heavy premiums would make the claim readily payable. Many companies have completely stopped selling Long Term Care Policy Insurance because they were losing money due to high incidence of claims. Those companies who still sell long term care insurance only sell to people with extraordinarily good health, and who can afford the high premiums.  And yet they still do not pay.  

If you were smart enough – or just lucky –  to purchase a long-term care insurance policy years ago, before the insurance sector tightened up on selling policies, you may face an uphill battle when trying to make a claim.  Arm yourself and be ready to battle.  This is a battle you don’t want to take on by yourself, and you don’t have to. The Newfield Law Group has for decades handled these cases, and our experienced and aggressive attorneys know how to fight back against insurance company tactics that have been developed over many years.

As more Americans need care from a nursing facility or a home health care aide, they are finding out that the insurance companies they counted on seem to be determined to pay as little as possible or not at all. The Newfield Law Group represents people just like you who paid premiums for decades to protect themselves and their savings from the exorbitant costs of long-term care.

Why Was My Long-Term Care Insurance Coverage Denied?

While there are many different tactics used by long-term care insurance companies to deny claims, the underlying reason for the denials and delays are two-fold: the insurance companies are chasing profits and doing everything possible to mitigate liability.   

When long-term care insurance policies were originally sold, the insurance companies’ actuaries and economists expected the policies to be profitable. Over the years, improvements in medical care and medicines extended the length of the average American’s lifespan, while dramatically increasing the cost of healthcare. Paying benefits on long-term care policies has become less profitable for the insurance companies, which is why many insurance companies have sold their long-term care insurance divisions. Those who are left are doing everything they can to maximize profits for shareholders. Your claim is their unwanted overhead. 

Despite this, claims are being paid out at higher amounts each year.  

 

Can You Fight Back on a Denied Claim?

You can fight back when a claim is denied, when the long-term care insurance company is asking for an overly burdensome amount of paperwork, or if the company is delaying paying benefits.

This is a classic David vs. Goliath scenario that you don’t want to take on by yourself. Long-term care insurance companies have deep pockets, many law firms to represent them, and doctors and nurses on retainer to declare that you or a loved one do not qualify for care. You need an aggressive insurance law firm, with the experience and the tenacity to fight back.

A long-term care insurance policy is a contract between the claimant and the insurance company. Like many contracts, the long-term care policy is dense with legal complexities and is difficult for a layperson to understand. 

Note that every situation is different, and we can explore them with you during a free consultation – call (877) 406-7883 to learn how we can help. 

We know it’s not fair, but it’s true: if the insurance company gets a call or a letter from a law firm, rather than a claimant, the response will be different.

Here are the most common reasons for a long-term care claim to be denied.

There are six activities of daily living (ADL), and claimants need to be able to prove that they are medically unable to perform at least two of them. 

  1. Bathing, including taking a shower, brushing teeth, and grooming unassisted.
  2. Getting dressed and undressed.
  3. Meal preparation and eating
  4. Toileting and continence – including control and hygiene.
  5. Functional Transferring – walking to and from rooms in your home
  6. Getting in and out of bed safely

Typically, long term care insurance for nursing home costs requires that an individual be unable to perform two or more of the six ADLs. Coverage all depends upon the language in your policy and the long term care insurance company’s determination of whether or not you are truly unable to care for yourself and satisfy the criteria outlined in the specific policy. 

Activities of Daily Living or ADL

Proper Licensure of Facility as an “Eligible Care Provider”

One of the provisions used to deny claims is the licensing status of the facility where long-term care is being provided. It is extremely important to review the policy and be sure that the facility under consideration will be covered by the policy. Don’t sign any contracts with the nursing home without finding out the facility’s licensing status.

Very often, a patient cannot be sent directly home after receiving care in a hospital. They need to receive a certain level of care, medications, or therapies. When this occurs, families will often go to long-term care facilities and meet with the admissions staff to determine whether or not there is a bed available, if the kind of care the person needs is available at the facility, and if the facility accepts the long-term care insurance policy. There are instances when the hospital pressures the family to move the patient and the care facility also wants a fast decision. This is never good for the patient, especially if one of the family member’s takes the “We don’t care how much it costs” position—which sounds great but doesn’t work out once the first invoice is received.

Be sure the facility meets the criteria set in the long-term care policy. It may have language that indicates broad coverage for nursing homes, limited coverage for assisted living, or licensed home care with a properly licensed agency.

What if The Facility Is Not Properly Licensed?

The company running the nursing home or assisted living facility must prove to the long term insurance company that it is an “eligible care provider.” The licensing or criteria sometimes depends on having the appropriate staffing and specific services, along with the necessary state licensing. It seems like something you should be able to find out before moving into a facility, but very often the time between being discharged from the hospital into a nursing care facility with available beds is short and the facility that accepts your long-term care policy for coverage may not have the services needed. 

Read the fine print. Some LTC policies will pay for home health care, but only if the caregivers are licensed and work for a licensed agency. Even if you are paying for this yourself during the elimination period, the elimination period is also subject to qualifying factors.  Thus, even when eligible on the core elements, other aspects of a claim must be proven.

No Prior Hospitalization

Over the years, terms and limitations in long-term care policies have changed. Factors that might have been acceptable to the long-term care insurance company ten years ago are no longer permitted. At the same time, older policies include provisions that haven’t seen the light of day in years. One of those is called the “gatekeeper” provision, which requires that before you can receive benefits on your long-term care insurance policy, you need to have had either a hospitalization, a nursing home stay, or, in the worst case scenario, both, before the insurance company will deem you eligible for coverage.   Hurdles exist at every turn, and having an experienced attorney to guide you would be a wise choice.  

Conflicting Medical Opinions.

Here’s where Long-Term Care Insurance and Long-Term Disability Insurance are alike: denying coverage based on medical status. The long-term care insurance company has a doctor review medical records and determines, without even examining you, that you don’t meet the requirements for long-term care. 

We know from long experience how flawed these paper reviews are. We also know that sometimes the insurance company’s doctor or nurse is only provided with a small part of your medical records. Or that you may have a complex issue and they have no background or specialized knowledge of your issue. It takes strong representation to overcome this denial, including knowledge and experience with medicine and the law.

There’s an inherent conflict of interest here. Is the same doctor or nurse who is being paid by the insurance company have the ability to be completely unbiased, when they know the insurance company’s preference is not to pay your claim? This is an issue we have encountered numerous times throughout our practice of insurance law. Even courts recognize this and call it out when they see how overt it can be. 

Alleged Nonpayment of Long-Term Care Premiums

Every payment for a long-term care premium should be noted not just in your checkbook but documented to demonstrate proof of payment.  Never let a policy lapse.  A copy of a canceled check or an email confirming receipt of payment should be secured.  A long term care insurance attorney will be able to tell you what time limits your policy has if nonpayment is an issue.

There are instances where an elderly person might forget to pay a premium, but states have laws to protect consumers. Often, there is an option to have another person, usually an adult child, named as an alternate contact just in case a premium is missed because of illness or diminished capacity.  A declaration of proof of cognitive decline from a physician may be enough to reinstate coverage, but some long-term care insurance companies are not so easily satisfied.

Benefits for Personal Care Not Part of Your Policy

Here’s where having an experienced long term care insurance attorney can help. The insurance company says that the policy does not cover personal care, which typically includes light housekeeping or having someone who can run errands for you – going shopping, etc. But is that correct? Without being able to skillfully review and understand the provisions in your contract, you may have this coverage after all. 

Do You Have a Plan for Care?

There is an assessment of your health condition and must be completed at least every 90 days after the first time it is conducted. If it is not provided in a timely manner, the long-term care insurance company can stop paying benefits. 

Elimination Period and Calendar Days

Some companies will begin paying benefits 60 days after you file a claim.  Others count on “service days,” counting only the days you pay for home health care, for example. If you have a person coming to the house to help you three days a week, only those three days are counted as part of the waiting period. It will take 20 weeks before benefits kick in. In the meantime, you or your family must pay out-of-pocket.

As soon as there is a problem, file the claim. The insurance company will review the claim and may send a nurse or a social worker for an at home visit. We tell our clients they should never be alone with any insurance company representative during a home visit. A trusted family member, an adult child, or a responsible friend should be present. Any interaction with insurance company representatives of any kind should be documented and, if in person, witnessed, by another person.

The treating physician must confirm in writing all of the details of the claimant’s disabilities, including a prescription for home health care seven days a week or nursing home care for life. The doctor’s report must reflect the kind of care that is needed.   

Your representative should be the contact, not the patient, especially if they are infirm or suffering from Alzheimer’s. No one likes to admit how sick they are, and a dementia patient could have a brief moment of clarity that the insurance company representative characterizes as a reason not to receive benefits.

Claims Involving COVID   

Many people who contracted COVID have experienced disabling symptoms long after the initial illness passed, which today is recognized as “Long COVID.” These patients experience cognitive impairment, muscle weakness, pain, chronic headaches, and depression and/or anxiety. Some are diagnosed with POTS (postural orthostatic tachycardia syndrome), a nervous disorder that doctors believe can be triggered by COVID. Others sustained damage to their cardiovascular, kidney, respiratory and neurological systems, making them too ill to care for themselves. 

If you or your loved one needs nursing care or other coverage pursuant to a long term care policy because of Long COVID, it is possible you may face additional challenges from the long term care insurance company. Long term insurance companies are reticent to provide coverage, denying claims on the basis of “not medically necessary,” or any handful of outlined reasons.   

Why You Need a Long-Term Care Insurance Attorney 

We can advise you on your rights under a long term care insurance policy.  Where appropriate, we can fight for your claim against any major insurance company nationwide. Please call our office at (877) 406-7883 to speak with an attorney and learn about your options. The call is free and there’s no obligation.