Winning a Long Term Care Insurance War

Attacking the insurance company medical expert and obtaining a detailed, in-home nurse evaluation to force the insurance company to pay.

The Challenge 

A long term care insurance policyholder who was unable to live independently due to disability was frozen after a long, back-and-forth battle with the insurance company. After originally paying the claim, the insurance company terminated benefits. The policyholder hired a lawyer, who filed a lawsuit. The lawyer died two months after filing suit, and another lawyer took over. At one point, the insurance company briefly resumed paying benefits, only to terminate them again. By the time the policyholder came to Schwartz, Conroy & Hack PC, the case had been dormant for five years.

In the meantime, the insured remained unable to safely perform a number of activities of daily living (known as “ADLs” in long term care insurance policies), caused by multiple disabling medical conditions. Disabling conditions include (1) fibromyalgia, a connective tissue disorder that causes chronic muscle pain and tenderness in many areas of the body, (2) brittle bones due to advanced osteoporosis, as well as vertigo and balance issues due to Meniere’s disease, an inner ear condition.

As a result, the client needed assistance with bathing, transferring and dressing, among other things, and needed to demonstrate a need for assistance with 2 out of 6 ADLs to qualify for benefits.

The Solution

We took over the case and amended the lawsuit to not only attack the insurance company’s determination not to make future payments on our client’s claim, but to cover the past intermittent periods during which the benefits went unpaid.

The insurance company had based its final denial of the claim on an assessment by a doctor it hired to examine the policyholder. We not only got our medical expert to attack that examination, but we also hired a nurse to perform an on-site evaluation of our client’s functional abilities.

The results of this evaluation, combined with our expert’s testimony, allowed us to demonstrate that our client was unable to perform multiple ADLs and was therefore entitled to long term care benefits under the terms of the policy. We also unearthed an initial report created by the insurance company’s examining doctor that was written more favorably to our client’s claim, but was altered at the insurance company’s request.

The Result

Through tenacious litigation and an intimate understanding of the policy and the claims process, Schwartz, Conroy & Hack PC obtained for the client a major portion of what was owed retroactively, in addition to agreeing to pay a fixed monthly benefit going forward for the rest of the client’s life. 

If you need help with a long term care insurance claim, contact us today for a free consultation.

Evan-SchwartzEvan S. Schwartz
Founder of Schwartz, Conroy & Hack