Long-term care services are often needed when individuals have difficulty performing daily activities independently due to aging, illness, disability, or cognitive impairment.
When our clients need assistance with activities of daily living (ADLs), long-term care insurance is designed to help them pay for the costs associated with long-term care services, typically not covered by health insurance or Medicare.
These various care settings and services include in-home care, assisted living facilities, adult day care centers, and nursing homes, which makes long-term care insurance instrumental to their quality of care and overall quality of life.
When insurers delay, undervalue, or deny long-term care benefits, individuals and families are in a challenging position that can impact their physical, emotional, and financial well-being.
We want to help.
At Disability Insurance Law Group, our Fort Myers long-term care insurance claims lawyers represent policyholders in Florida and nationwide to help ensure their rights are protected throughout the claim process.
If you and your family are counting on your long-term care insurance to pay for your medical and ongoing care needs and are now facing a coverage dispute or denial, contact our experienced Lee County insurance claims attorneys today for help.
Long-term care insurance claims can be disputed or denied for various reasons, depending on the specific circumstances and the terms of the policy.
While each case is unique, here are some common reasons why a long-term care insurance claim might be disputed or denied:
The insured person may not meet the eligibility criteria outlined in the policy. Common eligibility criteria include being unable to perform a specified number of activities of daily living (ADLs) or being diagnosed with a cognitive impairment that meets the policy’s requirements.
Many long-term care insurance policies have an elimination or waiting period before benefits become payable. During this time, the policyholder is responsible for covering care costs. A claim may be denied if submitted before this waiting period has elapsed.
If the policyholder fails to pay premiums and the policy lapses or is canceled due to non-payment before the need for long-term care arises, benefits will not be available.
Insufficient or incomplete documentation of the insured person’s condition or care can lead to a claim denial. Proper medical records and documentation of the need for long-term care services are essential.
Each policy has specific criteria that must be met to trigger the payment of benefits. This may include requirements related to the severity of the insured person’s condition or the type of care needed. If these criteria are not met, the claim may be denied.
Long-term care insurance policies often have exclusions or limitations for specific conditions or circumstances. For example, some policies may exclude coverage for care needed due to self-inflicted injuries or certain pre-existing conditions.
If the policyholder or insured provided false or inaccurate information during the application process or when filing the claim, and the insurance company can demonstrate that this misrepresentation was material and influenced the underwriting decision, the claim may be denied.
Some policies require qualified and licensed healthcare professionals or facilities to provide care services. The claim may be disputed if the care is provided by individuals or entities that do not meet these requirements.
The insurance company will no longer pay for long-term care services once the policy’s maximum benefit amount or benefit period is reached. The claim may be denied if the insured’s care needs continue beyond these limits.
If the insured person is eligible for long-term care benefits from multiple sources, such as long-term care insurance and Medicaid, coordination of benefits issues may need to be resolved. Failure to coordinate benefits correctly can lead to disputes.
If your long-term care insurance claim is disputed or denied, carefully reviewing the denial letter and policy documents is essential. We can help.
If you believe your claim has been wrongly denied or face challenges in the appeals process, contact our skilled Fort Myers long-term care insurance claims attorneys to get the guidance and assistance you need to navigate the appeals process successfully.
Our Fort Myers long-term care claims attorneys at Disability Insurance Law Group can effectively protect your rights as more than lawyers but advocates for clients’ rights against unfair treatment.
Our extensive experience enables us to identify situations where insurers fail to meet their legal and contractual obligations. No matter where you live in the U.S., our attorneys are well-versed in the processes and procedures involved in pursuing a long-term care insurance claim and protecting our client’s rights under state and federal laws.
Contact our skilled long-term care insurance claims attorneys in Fort Myers today by calling 954-989-9000 or contact us online to schedule a free and confidential case assessment so we can put our over 50 years of combined experience to work for you.
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