According to the Department of Health and Human Services, individuals who are over the age of 65 years have a 40 percent chance of living in an assisted living facility or nursing home. This is because approximately 60 percent of these seniors will be diagnosed with a bare minimum of chronic medical conditions that make patients require some form of long term care. It is for this reason that long-term care insurance is imperative. In most cases, long-term care insurance helps cover costs related to:

  • Assisted living or nursing homes,
  • Home health care,
  • Adult day care facilities,
  • Other services related to the care of seniors
  • Respite care,

Besides saving your family from the stress that goes along with trying to provide care to an ailing senior, long-term care insurance (LTCI) can help save your family from financial ruin. If you have purchased this kind of insurance, your insurance company has a duty to handle your claim in good faith. Unfortunately, not all claims are approved. It is common for claims to be denied. If your claim has been denied, you need to hire an attorney that specializes in bad faith insurance cases.

Stop Health Insurance Denial is a law firm that offers competent legal assistance to clients all around the United States, whose insurance claims have been denied. If your insurance company is acting in bad faith, we will make it accountable and see to it that you get what you are owed. Furthermore, we will help you understand all the facts about long-term care insurance denial that you may not be conversant with. The most important aspects to know include:

Not All Long-Term Care Insurance Denials Are in Bad Faith

We hear all the time how “evil” insurance companies deny long-term care insurance claims. After all, insurance companies are businesses that look for each opportunity to maximize their profits. Well, it is not usually the case. In some cases where insurers deny claims, it is because the insured persons did not fulfill the terms of their insurance contracts.

If you ask policyholders whose claims were denied, they will tell you that they thought that all they ought to do in order to be given compensation, later on, is to pay their premiums promptly. While premiums must be paid, there are also additional responsibilities that most people overlook. If you ignore them, you will only be frustrated when your long term insurance claim is denied.

Just like other insurance policies, long-term care insurance policies are “contracts of adhesion”, which means that one party, the insurer, drafts a contract and the other party, you, are given sufficient time to read the contract exhaustively. By signing the contract, your insurance company assumes that you read, understood and agreed to the terms of the contract.

After signing the contract, both parties are required to live up to their promise. If you fail to do as required, then your insurance company is within its right to deny your claim. If the insurance company fails to fulfill its obligation, then you have legal options. You can file an appeal and get paid what you rightfully deserve.

Common Reasons for Long-Term Care Insurance Denials

  1. Ineligible long-term care provider

Most insurance companies will insist that the assisted living facility or nursing home you choose to seek long-term care in meets their criteria for the eligible care provider. In most cases, the long-term care insurance policy requires that the facility have the appropriate personnel and care, in addition to a specific license. If the facility you are living in does not meet your insurer’s criteria, then your claim is likely to be denied.

To avoid long-term care insurance denial in future, it is best to find out well in advance if the facility you intend to live in meets the criteria of your insurance policy. You do not want to check into an assisted living facility or nursing home and then have to move out because your insurance does not pay for that facility.

  1. Not meeting the ADL requirement

Most long-term care insurance plans require that in order for you to be covered, you must be medically proved to be unable to perform at least two of the six basic Activities of Daily Living. These activities include eating, bathing, dressing, toileting, mobility, and personal hygiene. Most plans also pay claims to those who have been medically found to be a danger to themselves or others due to a mental condition or cognitive decline.

If you are filing an insurance claim only on the basis that you have gotten older and no longer feel like you did 30 years ago, you are most likely to be slapped with a long-term care insurance denial. In order for your insurance claim to be granted, your doctor must sign an affidavit that in his professional opinion, you are showing signs of cognitive decline, or that you are not able to perform at least 2 of the 6 ADLs.

  1. Getting short-term care

Your insurance claim will be denied if you are making it on the basis that you received short term care. Just like its name implies, long-term care insurance only pays benefits for long-term care. So, you can save yourself the frustration of a long-term care insurance denial by keeping in mind that this type of insurance cover is only intended for patients with long-term care needs.

Along with saying that you have cognitive challenges or that you are not able to perform at least 2 of the 6 ADLs, your doctor must also sign an affidavit saying that, in his professional opinion, you need long-term care lasting at least 90 days. If your doctor believes that you will recover your ability to function in a shorter time, then it means that you do not need long-term care. To enjoy the benefits, you will need to prove that you had a nursing home stay, hospitalization confinement or both before your insurance company agrees to pay.

  1. Unacceptable “Plan of Care”

Most insurance companies require that policyholders present a written Plan of Care when filing a long-term care insurance claim. If you do not have one, then you are most likely to get an insurance denial. Having a Plan of Care doesn’t necessarily mean that you will be automatically approved. If the Plan of Care is not well written, then it will most likely be disregarded and your claim denied.

To ensure that you will not be denied benefits, you need to hire a Plan Coordinator to write the Plan of Care. Since Plan Coordinators are professionals that are conversant with what is required by insurance companies, they are in a position to write a Plan of Care that satisfies insurance companies, hence minimize the probability of long-term care insurance denials.

  1. Failure to observe deadlines

Your insurance policy will stipulate the duration of time in which you should file your claim. If you do not adhere to these strict deadlines, then your claim is most likely to be denied. It is, therefore, important for you to adhere to the stipulated deadlines to ensure that you will file your claim on time.

Additionally, you should attach proof of timely filing when submitting your claim. That proof of timely filing should be something that shows when you initially submitted your claim and the number of times you resubmitted it. If you submitted your business insurance claim electronically, i.e. via email, you should print an electronic report indicating the initial submission.

While filing a claim after the deadline is one of the reasons why your insurance company can deny your claim, its decision to deny your long-term care insurance claim can be reconsidered if you had a valid reason for not submitting your claim on time. So, if you have a valid and verifiable reason as to why you were not able to submit your long term care insurance claim within the deadline, you can file an appeal. Stop Health Insurance Denial can help you with this intricate process.

  1. Omitting relevant details

Submitting your insurance claim without certain crucial details will most likely result in a long-term care insurance denial. Errors and omissions are some of the causes of insurance denials, and your insurance company will not hesitate to deny your claim if you have made mistakes in your application.

Therefore, it is important to provide all the relevant information accurately when filling out your application. This includes your full name, date of birth and social security number. Also, be sure to submit current information, especially in the case of addresses.

The Process of Filing a Long-Term Care Insurance Claim

  1. Carefully review your LTCI policy terms

A long-term care policy is a contract between the insurer and the insured. An insurance firm will cover specific expenses so long as the policyholder meets the terms and conditions set out in the policy. Remember that long-term care insurance policies vary from an insurance provider to another. It is, therefore, important for you to carefully review your LTCI policy terms and conditions to understand what is and what is not covered. Your policy will contain the following information:

  • Limitations on what types of facilities are eligible,
  • Limitations on what types of services are covered,
  • Waiting periods before you are eligible for LTCI coverage,
  • Specific insurance claim and appeals process,
  • Filing deadlines.

If you don’t already have it, you can ask for a copy of your LTCI policy from your insurance agent or company. You will find out that these policies use highly technical language, making them very hard to interpret. Even one simple mistake or error can result in a denial of your long-term care coverage.

If you are finding it hard to understand the terms and conditions of your long-term care insurance policy, contact an experienced insurance benefits lawyer. At Stop Health Insurance Denial, we help policyholders have a good understanding of their policies so as to prevent the probability of insurance denial.

  1. File your claim carefully

After thoroughly reading your policy and having understood all the terms and conditions, you can go ahead and file your insurance claim. This process usually involves the following:

  • You will have to complete a series of forms,
  • You will have to participate in an initial phone analysis,
  • You will then meet with an insurance adjuster for a face-to-face conversation,
  • You will be required to submit your medical reports from your doctor and the assisted living facility,
  • You will need to provide any other relevant details that will help explain why you are eligible for benefits.

The process of filing a long-term care insurance claim can be overwhelming, especially when dealing with a medical condition or cognitive challenges. An experienced insurance benefit attorney can be of great help in assisting you to complete this process quickly and efficiently.

Besides helping you complete this process swiftly; our competent attorneys help policyholders avoid mistakes that could lead to insurance denial. With us, we can help you complete the application process and present a compelling case of why you should obtain the benefits you deserve.

  1. Receive your benefits or file an appeal

After filing your claim, your insurance company will embark on an investigation to establish the facts. After conducting this investigation and having found out that you meet all the terms and conditions of your long-term care insurance policy, the company will approve your claim. If it finds out that you haven’t met the terms and conditions of your policy, it will deny your claim.

If your claim has been denied, you have the right to appeal. You have to bear in mind that long-term care insurance policies usually have strict appeal processes and deadlines. Before initiating an appeal, it is best to consult with a bad faith insurance attorney. Attorneys at Stop Health Insurance Denial can battle your insurance company on your behalf.

Things to Do When Filing an Appeal 

There is no reason for you to accept the fact that your claim has been denied. If you believe that you have satisfied the requirements of your long-term care insurance policy and your insurance company cannot give a valid reason as to why they have denied your claim, you have a right to appeal. The following are the things you need to do when filing an appeal:

  • Get all relevant documents 

Your medical records are crucial to this case as they can help prove that you have a medical condition that requires you to have long-term care. Your doctor’s affidavit will also help a great deal in proving that you meet your policy’s eligibility requirements for benefits. If you do not have these important documents and records yet, it is time to get them.

  • Understand and adhere to the requirements for the appeals process

 In their denial letter, the insurance company will provide you with information on the requirements you need to meet when filing an appeal. This includes the deadlines that you need to meet. If you do not meet these deadlines, then you will forfeit your right to your benefits. Therefore, it is important for you to understand and adhere to these requirements.

  • Keep a record of all communications with the insurance company

From the first call, you will make to the insurance company, to the letter, fax or email you write to the company, all are crucial to your case. So, it is important to keep a record of all communications with the insurance company. If the insurance company drags will deny having received your claim, you will have evidence that will help your case.

  • Follow up

If you do not receive a confirmation that your appeal has been received, it is important that you contact the insurance company right away. It could be that your application for appeal was not received. If the insurance company drags its feet in processing your appeal, you should not just sit back and relax. Be sure to make follow up calls to determine the status of your case.

Why You Need a Competent Attorney

If you filed for claims on your own and got a long-term care insurance denial, you should not attempt the appeals process on your own. The appeals process is even more intricate and require a competent attorney. The experience of an attorney can help you successfully file an appeal and hold your insurance company accountable.

You also need to remember that your insurance company will have a team of competent lawyers, adjusters and investigators to represent its interests in your case. So, it is prudent to have an equally competent lawyer to fight this battle on your behalf. Attorneys at Stop Health Insurance Denial know all the tactics used by insurance companies to deny the claim, thus can help you unearth them and avoid frustrations. If you contact us after your initial claim is denied, we will ensure that your insurance company will have no other option other than paying what it owes you.

Schedule a No-Risk Consultation

If you or your loved one has faced a long-term care insurance denial, we are here to help. Stop Health Insurance Denial assists families all over the United States get the compensation they deserve from their insurance companies. Our attorneys have extensive experience handling insurance claims for health benefits, life insurance, disability payments and long-term care insurance. Schedule a no-risk consultation by calling our office at 310-695-5241 or filling out our contact form.