After you have paid your long term care premiums for many years and have submitted a claim for benefits, it’s natural to expect that the claim will be approved. But long term care insurance companies – many of whom oversold policies decades ago for prices that do not support the staggering cost of benefits today – will look for any excuse to challenge or deny your claim. Here is a look at what to expect after your claim is submitted.
Insurance Company Scrutiny
Your insurance company will painstakingly scrutinize every part of your application, looking for a reason to deny your claim. The insurer will investigate whether the services you’re seeking are covered, whether your chosen long term care facility or home care provider is licensed and qualified to render services, and whether the dollar amount of benefits is accurate. The company will examine the validity of your plan of care and the doctor’s report that you have submitted, and it will seek the opinion of its own doctor to determine if your medical needs warrant long term care services and the level of care indicated. The insurance company also typically sends a healthcare professional to your home to get its own evaluation of your level of functioning.
How you handle the insurance company’s home evaluation can be crucial to the success of your claim. Do not meet alone with the insurance company’s representative, as you may misreport or underreport some of the struggles you are facing due to forgetfulness or embarrassment. Having a trusted family member or, preferably, a long term care attorney present will help ensure that your rights are protected throughout the evaluation and that the insurance company representative receives a thorough picture of your struggles and limitations. Further, your family member or attorney can take detailed notes in case there are discrepancies between the insurance company’s report of the encounter and what actually occurred.
If Your Claim Is Contested
After scrutinizing your claim and completing its evaluation, the insurance company may notify you that it is approving your claim, or it may contest or deny it.
If your claim is denied, you have the right to appeal or contest the decision. But you need to have a firm understanding of the reasoning behind the denial in order to decide if and how to challenge it. Many times, insurance companies are vague, stating your claim has not met the qualifications as defined in the policy, and it is not clear where it falls short. If this is the case, you need to send a written request and/or speak to the insurance company representative to get a clear reason for why the claim was denied.
Unfortunately, insurance companies bank on the fact that many of their aging customers will struggle to understand the process and be unable to advocate for themselves. It’s crucial to have an advocate, whether a family member or long term care attorney, to navigate the claims process.
Below are some of the common reasons long term care claims are denied.
Healthcare Provider Is Ineligible
Insurance policies require that assisted living facilities, nursing homes, home health care providers and other providers meet certain requirements, such as having specific licenses. Before choosing a facility or home health care worker, it is important to investigate whether that facility or provider meets the criteria detailed by your policy.
Policyholder Does Not Meet the ADL Requirements
Benefits for long term care policies are typically triggered when you can no longer perform at least two of the six Activities of Daily Living (ADLs) – which include eating, bathing, dressing, transferring, toileting and continence – or are cognitively impaired, and that these conditions are not expected to improve. The insurance company may counter that, according to its medical experts and in-home evaluation, your level of functioning does not meet the criteria for long term care.
Errors and Omissions
Your insurance company may deny the claim because of mistakes made in the application, missing information, or a plan of care it deems unacceptable. It is important to accurately and completely fill out all forms, provide a thorough plan of care from a qualified professional, and include all relevant supporting documents and records.
Failure to Meet Deadlines
Once you file a notice of claim, the insurer will require that you submit your claim within a certain amount of time. If your submission is late, the insurance company can deny the claim for failure to meet the deadline. Further, requests for follow-up information from the insurance company will have deadlines that must be met in a timely fashion.
Once you discover that your insurance company is contesting or denying your claim, it is highly recommended that you contact a long term care attorney, if you have not already done so. The claims appeal process is a legal minefield. You will be up against the insurance company and its attorneys, and you will need a competent attorney with expertise in long term care claims and litigation to guide you through the process. An experienced long term care attorney will know the best ways to attack a denial to ensure that you receive the benefits you deserve.
If you are considering filing a long term care insurance claim, or if your claim is being challenged or has been denied, give us a call. We successfully handle long term care claims on a daily basis and have the experience, knowledge and tenacity to make sure insurance companies keep the promises they made to you.
Contact us today for a free consultation.
Evan S. Schwartz
Founder of Schwartz, Conroy & Hack