By 2030, nearly 70 million Americans will be over the age of 65. Unfortunately, many aging people are unable to care for themselves without some form of assistance.
Today, as the need for long-term care increases, so does the awareness of long-term care insurance. Often referred to as LTC insurance, this type of insurance coverage can protect against the potential financial consequences of a long-term illness or disability.
Did you know that the chances of a person spending at least 2.5 years in a nursing home are one in three? According to the U.S. Department of Health & Human Services, nursing home stays would cost nearly $100,000 based on average rates throughout the country.
Protecting Financial & Emotional Health
As more families face the prospect of paying for long-term care in the coming years, long-term care insurance can provide financial protection, emotional well-being and peace of mind. LTC coverage can alleviate the potentially crippling fear of outliving your income and retirement savings.
Long-term care insurance can cover the cost of certain types of care if you need help with two of the six Activities of Daily Living (ADL) or you have a cognitive impairment:
- Hygiene (grooming, shaving and oral care)
- Eating/feeding yourself
- Toileting (being able to use the restroom)
- Transferring (such as getting in and out of bed)
However, it is important to remember that every policy is different, and the conditions for receiving long-term care insurance benefits may vary from company to company.
Understanding The Fine Print In Your Policy
Long-term care insurance policies have specific requirements you need to be aware of, which may include:
- Most LTC policies do not allow a family member to serve as caregiver; even more require the caregiver to be a licensed professional caregiver who is not a family member.
- Some policies allow you to continue living in your own home while you receive long-term care benefits, while others require a recipient of benefits to live in a facility.
- Many policies will not offer benefits unless you are unable to perform, without assistance, two out of six activities of daily living or are cognitively disabled.
Long-Term Care Insurance Denials
When you purchase long-term care insurance and pay your premiums, you assume that you will have the coverage you need, when you need it. Unfortunately, too many long-term care insurers find any reason possible to deny claims and coverage. Some common reasons for denials include:
Alleged premium nonpayment – If the insurance company believes that you missed a payment or paid late, the company might state that your policy lapsed and it doesn’t owe you benefits, despite all the premiums you paid. These companies must follow strict procedures regarding nonpayment claims, and we can try to help show that your coverage should still be active.
Facility licensure – Some insurance companies will challenge whether the care facility qualifies as a properly licensed and eligible care provider, and claimants must demonstrate proof of the facility or caretaker’s qualifications.
No hospitalization – Some older long-term care policies have provisions that require a policyholder to have a prior hospitalization, stays in care facilities, or other treatment before they can receive coverage for long-term care.
Denying personal care benefits – Some long-term care insurance companies try to deny coverage for personal care, which could include a caretaker running errands, keeping house or cooking for the policyholder.
Claims of cognitive impairment – Some policyholders with cognitive impairment forget to make premium payments if they don’t set up automatic withdrawals. Within a certain time frame, we can help demonstrate through physician statements and testing that the lapse in payment was due to cognitive impairment, which means the insurer should reinstate the policy so the policyholder can receive the assistance they richly paid for.
Limited abilities – For many long-term care policies to apply, a condition must prevent a policyholder from performing daily life activities, including cooking, using the bathroom, dressing, toileting, changing, transferring, bathing or even walking. Some insurance companies will deny benefits if a policyholder has limited abilities to complete daily tasks, even though independent living is no longer a safe situation.
Different medical opinions – Some insurance companies have their own physicians review a policyholder’s treatment records and determine their capabilities without ever examining the individuals. Frequently, those doctors lack the training or specialization needed to provide a qualified diagnosis. If the insurer’s paid medical consultant decides the policyholder does not need care, the insurance company might deny the claim.
Improvement of condition – When some people receive the care they need consistently, their condition and abilities might improve. This does not necessarily mean they should have an independent living situation, though a long-term insurer might claim their improved condition renders them ineligible for continued benefits.
Excluded medical conditions – The fine print of a long-term care policy might have exclusions for certain conditions, including self-inflicted injuries, substance use-related illnesses, or preexisting conditions. An attorney can examine your policy language to determine whether an exclusion should or should not apply.
Receiving a long-term care coverage denial can be distressing, but many denials are erroneous or in bad faith. An experienced long-term care insurance lawyer can review the reasons for the denial and identify areas for a possible appeal to make sure that you receive the full coverage you deserve for the premiums you paid.
Overcoming Insurance Company Obstacles
Unfortunately, long-term care coverage is only as valuable as your ability to obtain benefits when the need arises. Insurance companies have a history of unreasonable denials, acting in bad faith against older policyholders.
At DarrasLaw, we provide skilled representation coupled with a compassion borne from decades of experience pursuing insurance litigation.
Needing long-term care is a difficult change for any individual or family. No one should have to suffer the added insult of being denied the long-term care insurance benefits they paid for and rightfully deserve.
Contact our experienced attorneys. We are focused on minimizing the stress on your family, maintaining your personal dignity, and ensuring you receive the benefits you deserve.
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“Jo-Ann, Just wanted to send you a note to thank you and the TEAM that helped me receive the funds I was due. I thought this was going to be a long drawn out thing with the insurance company but your team was super- fast on this. I will always remember your firm and if I hear of anyone else who needs your assistance. I know I can’t tell anyone about my deal but I will let them know there is real help at DarrasLaw. Tell everyone that I said hello and please thank them for me. Thank you Again!!!”
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