Delayed or Denied Claims for Long-Term Care

Common Claim Delay or Denial Tactics Employed by the Insurance Company

Insurance companies spend a great deal of time and money training their claims examiners and investigators to highly scrutinize every claim filed. Insurance companies often take advantage of unrepresented claimants by employing unfair tactics to delay and deny claims. They also employ in-house and local attorneys to vigorously defend and litigate insurance cases. Without legal representation, your ability to overcome such resources may be limited. Contact Di Law Group to discuss your legal needs in a free consultation.

Slow Walking

Insurance companies regularly delay payment of insurance benefits by simply continuing to request additional, duplicative and seemingly unnecessary information and documentation. The insurance company will assert that without this additional information, it is unable to approve your claim for insurance benefits. This can go on for months and even years if the insurance company is allowed by you to continue.

The sad truth is the insurance company is employing a delay tactic called slow walking to avoid paying the claim. Even sadder is that many claimants may give up the fight against the insurance company that outnumbers them in resources because they are too disabled or sick, or they may even die before benefits are paid. Don’t give up your claim. Contact us for a free consultation to find out how one of our attorneys can help you appeal this delayed claim.

Lapse of Policy Due to Nonpayment of Premiums

When the need arises for you to file for your long-term care benefits, or your loved one’s benefits, you may suddenly learn that premiums are outstanding and unpaid. What insurance companies refuse to acknowledge is that many times the premiums are unpaid because the insured suffers from a condition such as Alzheimer’s or dementia that affects his or her ability to remember to do things such as pay premiums, the insured became too ill too quickly and was unable to keep up with bills or the insured was forced to pay hospital bills instead of premiums.

Because of these common reasons for nonpayment of premiums, there may be requirements under your policy and the law that require that the insurance company give the insured a certain period of time to become current with premium payments, and also require that a “third-party designee” be notified of missed premium payments. Our attorneys aggressively assert your rights to have your policy reinstated and benefits paid in these circumstances, even when the deadlines may have passed under the law or your policy for reinstatement.

Denial Because of a Limitation Under Your Policy

Common denial tactics used by insurance companies in long-term care claims include the following:

• You weren’t hospitalized prior to needing long-term care, and thus the insurance company has denied your claim
• Because you do not suffer from an acute medical condition, your benefits have been denied
• The long-term care services that were provided to you were not provided by a registered nurse, licensed practical nurse or other properly qualified professional as defined under your policy, and the insurance company has denied benefits for these services
• The care or services were provided to you by a family member and the insurance company asserts that these are not covered
• The long-term care services that were provided to you were not provided by a nursing home or home care provider that is certified by Medicare
• The insurance company is alleging that the long-term care services provided for you are available under Medicare or another governmental program, and thus denying your benefits arguing that these services are not covered
• The long-term care services that were provided to you are not covered “skilled care,” and the insurance company is refusing to pay
• The insurance company is asserting that you are able to perform your “activities of daily living” and are refusing to pay for your long-term care claim(s)
• The insurance company claims that the care or services that you received are unrelated or unnecessary for you to carry out instrumental activities of daily living or unrelated to needs because of a cognitive impairment, and has denied benefits
• The insurance company hired its own doctor to review your claim, or to examine you, and now is asserting that their doctor finds that you do not qualify for long-term care benefits, even though your doctor is stating that you do
• The insurance company has denied certain types of long-term care provided, asserting that you did not need the level of care that you were provided
• The insurance company states that you have not provided sufficient ongoing verification of long-term care needs and thus has denied benefits
• You suffer from a pre-existing condition, and thus the insurance company is denying your benefits
• The insurance company asserts that your medical condition is not covered because it is the result of one of the following — mental illness, attempted suicide or intentionally inflicted injury, alcoholism or drug addiction, war or acts of war — and denied your claim
• The insurance company has denied your benefits because it asserts that you have received care in a government facility or outside of the United States and its territories

Appealing a Denial of Insurance Benefits: Defending Your Legal Rights

Many wrongful denials of insurance benefit claims can be overturned without the cost, frustration and delay of filing a lawsuit, simply by supplying the right information and knowing how to respond to your insurance company’s accusations.

Understanding the common tactics utilized by insurance companies and recognizing their deceptive behavior is essential in securing your rights and preparing an effective response. Before you proceed, it is vital that you understand your rights and obligations under your insurance policy and the law that governs your claim.

If you fail to meet your obligations, you may unknowingly be fatally destroying your claim. Your response to your insurance company’s wrongful denial of your long-term care insurance claim depends on the law that governs your claim. Private insurance policies, purchased independent from your employment, will fall under your state’s contract law. However, most group insurance policies, obtained as a product of employment (whether you pay your premiums or your employer pays the premiums), fall under the federal statute, ERISA. Both types of claims have unique and specific requirements for claimants in responding to their insurance company’s wrongful denial.

Let One of Our Long-Term Care Insurance Attorneys Fight for You

The law governing insurance benefit claims, including long-term care insurance, is complex and constantly changing. Our attorneys understand what is at stake when you must file a long-term care insurance claim. If you or a loved one is injured or is suffering from a serious illness that affects your ability to care for yourself, will you be able to collect benefits under your insurance policy to cover the cost of expensive long-term care services? Will your insurance carrier abide by the policy terms and pay your claim? Your need for long-term care and the steep costs for this type of care do not stop if your insurance company denies your claim. How will you proceed when you and your family’s financial future is at stake?

We understand that the reason our clients pays premiums for these types of policies is to protect their family, their income and their future. Our cases are not typical cases – an individual and their family’s future is at stake. We respect that our clients either will be in financial distress if their insurance claim is denied or already are in financial distress due to a denial of benefits. When a person is dealing with a prolonged illness, serious injury or even death, they are facing one of the most difficult times in their life.

Contact Disability Insurance Law Group

To discuss your legal needs with an experienced long-term care insurance lawyer, please contact us today to schedule a free and informative consultation, by calling us toll free at 954-989-9000 or by using our online contact form. Disability Insurance Law Group serves clients nationwide.