Long-Term Care Insurance Lawyers

You bought long-term care insurance so that help with needed assistance in performing activities of daily living or managing with dementia would be paid for if you ever needed it, and so that the cost of that care would not drain your savings. When the insurer denies the claim, delays payment, or stops paying, you are left covering the cost of care the policy was meant to pay for.

Whether you obtained long-term care insurance through your employer or purchased it individually through a broker, you have legal options if the insurance company denies, discontinues, or delays payments that you have a contractual right to receive.

What Long-Term Care Insurance Covers

Long-term care insurance pays for help needed to perform everyday activities when age, illness, or injury makes them hard to manage on your own. Depending on the policy, that help can include:

• Care in a nursing home or skilled nursing facility
• Assisted living and other residential care
• In-home help from a home health aide or a nurse
• Adult day care and respite care
• Memory care for dementia, including Alzheimer’s disease

Policies generally begin paying after a short waiting period once you need help with a set number of activities of daily living: bathing, dressing, eating, using the toilet, moving between a bed and a chair, and continence. Most require the need for assistance or standby assistance with at least two of them, which is the standard federal tax law uses for tax-qualified long-term care policies. A policy may also pay when a cognitive impairment such as dementia means you need supervision for safety. Your policy identifies the trigger for coverage, the daily benefit, and the waiting period before benefits commence, and those details often decide whether a claim is paid.

Why Long-Term Care Insurance Claims Are Denied

A claim can be denied, delayed, or underpaid even when the family can see that the need for care is real. These problems come up often:

• The insurer’s assessment does not match what the family sees. Insurers may send an assessor to the home. An older person may have trouble answering the questions, or may not want to admit needing help, and the report can understate the need. Having a family member at the assessment helps, and a new assessment or the care facility’s plan of care can correct the record.
• The facility or caregiver does not meet a policy requirement. Some policies require a facility to hold a particular license or to have a nurse present on the premises at all times, or require a home health aide to hold a certification. Some pay for home care only when the insurer has approved it under the policy’s alternative plan of care provision.
• The bills do not match the benefit. Many policies reimburse only the care charges you have incurred. A daily benefit is not paid unless invoices show care costs for those days.
• The policy was written before the care became common. Many older policies do not mention assisted living or home health aides because those services were uncommon when the policies were written. Vague wording leaves room for the insurer to read the policy in its own favor.
• The waiting period has not been met. Many policies pay only after an elimination period, a set number of days of care that you pay for first, and the insurer and the family can disagree about when that period started.
• The policy lapsed after a missed premium. Dementia or another cognitive impairment can cause a policyholder to miss payments without realizing it.

Many of these disputes turn on the exact words of the policy. Recent litigation has clarified some of these questions, but not all of them.

How Our Long-Term Care Insurance Lawyers Help With Your Claim

When a family seeks our assistance in challenging a denial, our services encompass the following:

• We compare the denial letter with the policy, because an insurer sometimes cites a reason or a provision the policy does not support.
• We obtain a copy of the insurance company’s claim file and fill the gaps in it, such as missing medical records, the facility’s plan of care, or a new assessment.
• We file an appeal within the insurer’s set deadline that addresses each of the insurer’s reasons for denial with evidence supporting coverage. An objective appeal built on records does more than accusations of bad faith.
• We use other routes when they fit the policy, such as mediation, arbitration, or a complaint to the state insurance department.
• We take the case to court when the insurer still will not pay, including claims for bad faith where state law allows them.

If rising premiums have you weighing whether to keep your policy, we can review your policy and help you make a decision on whether to keep the policy.

Consult an Experienced Attorney About a Long-Term Care Insurance Claim Denial

At DeBofsky Law, we handle long-term care insurance disputes for clients throughout the U.S. With offices in Chicago and Seattle, our firm has been recognized as one of the leading insurance litigation firms in the country, and founding attorney Mark D. DeBofsky is among the best in the nation. The firm’s 65+ years of combined legal experience handling insurance and employee benefits cases has demonstrated a proven track record and has resulted in numerous precedent-setting cases in various U.S. Courts of Appeals.

Any one of our seasoned attorneys can handle your case through every step of the claim process, claim appeals, and litigation. We have dealt with nearly every major insurance company on issues involving long-term care insurance and know how to handle your claim to achieve the best possible results efficiently and effectively.