Patterns In Long-Term Care Insurance Denials, Part 2

After paying the premiums for long-term care insurance coverage for years, it can be emotionally upsetting and financially devastating when the insurance company denies a claim for benefits. Unfortunately, this scenario is not uncommon. Long-Term Care insurers utilize a number of tactics designed to challenge and deny valid claims.

In part 1 of this post, we talked about how these insurance companies draft policy language in a manner that appears ambiguous and favorable to the carrier, and how they rely on that ambiguity to routinely deny claims. Today, we will discuss several other unfair and deceptive patterns used by long-term care insurers to deny claims.

Policy lapse

Imagine the stress of going to file your (or your loved one’s) long-term disability insurance claim and being told that the policy was canceled because the premiums had not been paid for a few months. Lack of payment for up to six months may not cause a policy to cancel. There are relevant laws and policy terms that may allow the insured to pay all unpaid premiums and keep the policy in force.

If missing payments can be attributed to the policyholder having developed dementia or severe cognitive decline, there may be contractual terms in the policy that allow for late payments to be accepted, language in the policy regarding the steps to be taken and provision for notification to a third party if a payment is late as well as state law that will protect the insured’s coverage in certain instances. Some carriers will quickly cancel policies for late premium payments in the hopes that the insureds are unaware of their rights or ability to have the policy reinstated.

Claimant interview

As part of the claims process, the insurer schedules an onsite interview in order to assess the claimant and obtain details about their medical conditions, functional limitations, and the home-health care or long-term services needed. A trusting claimant is unlikely to suspect that the interviewer is not really there to fully understand the claimant’s limitations and needs, but rather to find reasons upon which to base a denial. Questions may be vague, and the interviewer might not ask appropriate follow-up questions, accurately note their observations or give the claimant the opportunity to fully explain their limitations.

It is a good idea for an attorney to prepare the claimant for the interview and to be there during the questioning.

Slow walking

This phrase brings a mental picture of someone dragging their feet, which is what some insurance companies figuratively do to get out of paying valid claims. Basically, they delay fully assessing the application and/or make continuous requests for information and documentation, much of which is unnecessary or redundant, in an effort to avoid claim approval and the payment of benefits. The hope appears to be that the claimant or their family will eventually give up on the claim after being worn down, or even worse, that the claimant will even pass away.

Involve legal counsel early

These and other tactics can make it frustrating and challenging to get a valid claim approved. Talking to an attorney as early as possible – even before filing the claim – can make the process smoother and result in a faster resolution. The attorney will help the claimant and their physician(s) complete the forms, make sure the information required to adequately prove their right to benefits is submitted and will handle all communication with the insurance company. This generally ensures that the claim is timely reviewed and that the insurer pays all benefits due and owing to the claimant.

In cases where the company has already denied benefits to the insured, getting an attorney involved at a later stage is still beneficial. There are options for appeal, the filing of a bad faith notice with the state insurance commissioner and litigation if necessary. If you or a loved one is considering applying for Long-Term Care or Home-Health Care benefits and has questions or if you have started the process and have either been denied or continue to wait for a determination, please contact the attorneys at Disability Insurance Law Group for a free consultation at 954-989-9000 or visit our website at www.DiLawGroup.com.