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Has Your Insurance Company Denied
Your Disability Claim?

Whether an insurance company, employer, union or other ERISA governed
plan has denied your insurance claim, we can help.

What Is Insurance for Long-Term Care?

Long-term care insurance (LTC insurance) is a type of coverage for those who can no longer care for themselves due to a disability, chronic illness, cognitive impairment, or loss of functional capacity. Although these insurance policies are not based on age, the elderly are most in need of these policies. Policies for long-term care may include in-home assistance with daily activities. They also include care in nursing homes and assisted living centers. Long-term care insurance policies cover a range of treatments that are not covered by standard health insurance policies or Medicare. The purpose of LTC insurance is to pay for all long-term care expenses that regular insurance typically does not cover. Insurance claim denial in BostonPeople have grown increasingly conscious in recent years of the ease with which long-term care expenses may wipe out the life savings of older individuals. LTC insurance can be costly and frequently provides limited benefits, with restrictions and conditions that may cover only a tiny proportion of overall long-term care costs. Therefore, it is crucial to have an LTC attorney evaluate your policy to ensure that you understand the details of your plan and the benefits you may or may not be entitled to receive. A health care professional must find that you have a significant cognitive impairment or have lost the functional capacity to conduct at least two out of the six Activities of Daily Living (ADLs) for a minimum of 90 days in order for you to be eligible for benefits.

The Six ADLs are below:

  1. Bathing is the act of washing oneself with a sponge or in a tub or shower, including the process of entering or exiting the tub or shower.
  2. Maintaining control over bowel and bladder function, or executing associated personal hygiene while unable to maintain control over bowel or bladder function.
  3. Dressing entails donning and removing all appropriate clothing as well as any required braces, fasteners, or prosthetic limbs.
  4. Eating is the act of ingesting food into the body either orally, through a feeding tube, or intravenously.
  5. Using the restroom, including getting on and off, as well as carrying out any necessary personal hygiene
  6. Transferring is the act of getting into or out of a chair, bed, or wheelchair.
Usually, the insured can meet the ADL triggers if the insured needs either actual assistance or stand-by assistance. A variety of in-home care services, including skilled nursing, unskilled nursing type services, various forms of therapy, and personal care help, may be covered by long-term care insurance coverage. Additionally, some expenses for care in a nursing home, Alzheimer’s disease special care facility, assisted-living facility, adult day care facility, or hospice care facility may be covered by LTCI.

Common Reasons For Denied Long-Term Care Insurance Claims

When you purchase and pay premiums for long-term care insurance, you expect to have the necessary coverage when you need it. Unfortunately, a disproportionate number of long-term care insurers will deny claims and coverage for any reason. Common reasons for denials include the following:
  1. Alleged premium nonpayment – If the insurance company believes that you missed a payment or paid late, it may declare that your policy has lapsed and that it owes you no benefits, despite your having paid premiums. These companies are required to adhere to stringent procedures regarding nonpayment of claims, and we can attempt to demonstrate that your coverage should still be in effect.
  2. Licensure of the facility – Some insurance companies will question whether the care facility qualifies as a properly licensed and qualified care provider, and claimants must provide evidence of the facility’s or caretaker’s qualifications. Not all states license all facilities that should qualify for LTC insurance coverage.
  3. Some older long-term care policies have provisions that require a policyholder to have a prior hospitalization, stay in a care facility, or other treatment before receiving long-term care coverage. These provisions are unlawfully now.
  4. Denying benefits for personal care – Some long-term care insurance companies attempt to deny coverage for personal care, such as a caregiver running errands, cleaning the house, or preparing meals for the policyholder.
  5. Claims of cognitive impairment – Some policyholders with cognitive impairment forget to pay premiums if they have not set up automatic withdrawals. Within a given time frame, we can help demonstrate through physician statements and testing that the lapse in payment was due to cognitive impairment; therefore, the insurer should reinstate the policy so that the policyholder can receive the assistance for which they have paid so dearly.
  6. Insufficient skills – For many long-term care policies to apply, a policyholder must be unable to perform activities of daily living such as cooking, using the restroom, dressing, toileting, changing, transferring, bathing, or even walking. Even though independent living is no longer a safe situation, some insurance companies will deny benefits if a policyholder has limited abilities to perform daily tasks.
  7. Various medical perspectives – Some insurance companies have their own physicians examine a policyholder’s treatment records and determine their capabilities without physically examining them. Frequently, these physicians lack the training or and/or specialization required to provide a qualified diagnosis. The insurance company may deny the claim if the insurer’s paid medical consultant determines that the policyholder does not require care.
  8. Condition improvement – If certain individuals receive consistent care, their condition and abilities may improve. This does not necessarily imply that they should be able to live independently, but a long-term insurer could argue that their improved condition disqualifies them from receiving continued benefits.
  9. Excluded medical conditions – A long-term care policy’s fine print may contain exclusions for certain conditions, such as self-inflicted injuries, illnesses related to substance abuse, and preexisting conditions. An attorney can examine your policy language to determine whether an exclusion should or should not apply.
Many denials of long-term care coverage are erroneous or made in bad faith, which can be distressing. An experienced long-term care insurance attorney can evaluate the reasons for the denial and identify potential grounds for an appeal to ensure that you receive the full coverage you paid for with your premiums.

Comprehending The Small Print Of Your Policy

  • Even more policies require that the caregiver be a licensed professional caregiver who is not a member of the insured’s family.
  • Some policies allow you to remain in your own home while receiving long-term care benefits, while others require the recipient to reside in a facility.
  • Many policies will not provide benefits unless you cannot perform two out of six activities of daily living without assistance or are cognitively disabled.
Jonathan M. Feigenbaum, Esquire assists families nationwide with long-term-care insurance applications and appeals and litigation. We are respected disability insurance advocates with extensive experience handling claims for long-term-care insurance, disability payments, health benefits, and life insurance. We can help,  schedule a free, no-risk consultation by calling or completing a simple, online form.

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