Long-Term Care Policies And Denials

Accepting that it’s now time for a parent, loved one, or even yourself to seek the benefits provided by the long term care policy procured years ago and for which the premiums have been paid ever since is often difficult and life-changing. The one solace is that there is a policy to be utilized and thus much of the high cost of home health care and/or nursing care will be covered by the long term care benefits. Unfortunately, obtaining the long term care benefits to which the insured is entitled has become extremely difficult as insurers have become more reluctant to pay. Many insurance companies now employ numerous delay and denial tactics to avoid paying what often amounts to thousands of dollars in benefits per month for their insured.

Under most policies an insured will qualify for long term care (home health care or nursing home care) benefits if they are unable to perform two of the five basic activities of daily living (ADLs). These include eating, bathing, dressing, toileting, transferring to and from a bed or chair, and continence. Moreover, many policies state that the insured will qualify for benefits if they need either standby or hands-on assistance to complete two of the five ADLs. As such, the insured and their physician do not have to provide evidence that the insured is completely unable to dress, bathe or use the bathroom without physical assistance by another; but that the insured requires someone nearby to help them as they may not be able to safely complete the task on their own.

Despite medical evidence from their physician and statements from family, friends, or caregivers confirming the Insured’s inability to perform at least two ADLs without assistance, insurance companies employ a number of tactics to avoid paying these claims. Once common tactic is to misinterpret or misrepresent information in the medical records or provided directly by the claimant on the claim form or during the initial telephone interview. The carrier will purposely misconstrue that information to and state there is not sufficient evidence to show that the insured needs assistance with the activities of daily living. Another common tactic is for the carrier to incorrectly assert that the care provider, specifically the nursing home facility or home health caregiver, does not meet the qualifications required under the policy. Most policies require that the caregiver or facility is an eligible care provider. Thus, it is very important that you are familiar with the qualifications required under the policy and choose a qualified care provider. However, in some policies these qualifications are ambiguous and make it easy for the carrier to deny coverage.

In cases where the insured is cognitively impaired, the insurance company will claim that unless the insured requires 24/7 supervision they are not impaired under the policy’s terms and therefore not eligible for benefits. In most cases, this is a blatant misinterpretation of the policy language. Additionally, there are cases in which the insured suffers from dementia and the policy lapsed because they forgot to pay the premium. In most states, if the payment was not made by an insured due to dementia then they have up to six months before the policy can lapse. Often times, a letter from the insured’s medical provider sufficiently confirming the extent of their dementia may be enough to get the policy reinstated and benefits paid. Additionally, many policies provide the opportunity for the insured to name another person to whom the premium should be sent if payment is not made. As such, they may have failed to notify that person about the possible premium lapse. It is important to see if your policy or that of a loved one has this provision and designate a second person to be notified regarding unpaid premiums.

Other means used by insurance companies to delay the payment of a valid claim is to simply ignore telephone calls and letters related to the claim, continuously ask for information and documentation, despite having ample proof to pay the claim, and unreasonably prolong the evaluation process in the hopes that the insured goes away.

If you or a loved one have a long term care policy and are considering applying for benefits, have applied but no decision has yet been made, or been denied benefits please feel free to contact us at DI Law Group for a free consultation. We have extensive experience with these claims and would be happy to discuss your claim and options.