Written by attorney Michael John Hanson

Long Term Care Insurance Claim Denial Solutions

According to a The New York Times article I read recently, a woman was denied her long term care insurance claim because her policyholder said that she was not ill enough for coverage, even though she took 37 pills every day and had early-stage dementia. Four years after applying for her claim, her family had paid $70,000 while the policy had paid nothing. The same Times article noted that an 85-year-old woman with dementia was sent the wrong paperwork and then had her claim denied because of the "improper paperwork." We received a similar call to our office recently. After a careful review of the clients long term care policy and the denial letters, Managing Director Michael Hanson, who is an attorney and has worked for insurance companies, scheduled a conference call with our IKOR of Western Pennsylvania Registered Nurse Patient Advocate (RNPA) team and the IKOR USA corporate office. The result of this conference call was a new assessment and comprehensive process that we created around evaluating the activities of daily living for long term care insurance policies. Our process assists clients who have been denied long term care insurance benefits. In completing the assessment the IKOR RNPA visits the client in their environment interacting with family, caregivers, and health care providers. In this case the RNPA met with the client and caregivers at the facility where the client resides. She had conversations with family members, and gathered medical records from the clients’ physicians. After completing the comprehensive assessment around the activities of daily living, the RNPA worked with the clients’ physician, the caregivers at the facility and the family, to complete the needed paper work to submit to the insurance company. An additional outcome is that in working through the assessment process the RNPA worked with the facility, the family and the physician to create new care plans to improve the quality of life of the client outside of the activities of daily living in addition to getting the long term care insurance claim approved. Long term care insurance claims can be complicated, involving a lot of paperwork. Further complicating matters are that the people filling out the claim forms may not be the same as those who purchased the policy. For example, a client with dementia may need her son to fill out the claim, even though the son may not be familiar with the ins and outs of the policy. That can make filing the claim complicated and may also make appealing a denial incredibly complex as was the case with our recent client. In addition to complex paperwork and policy terms, it’s a tough time for the insurance industry right now and it's only going to get tougher given the advancing age of the baby boomer. Many aging clients have decided to err on the side of prudence and purchase long-term care insurance—an excellent product purchased for all the right reasons by careful, responsible citizens. By law, insurers are required to conduct their relationship with policyholders in good faith. A policy, after all is a legal contract—a signed agreement that spells out the obligations of each side. For the policyholder, the obligation is to be aware of the benefits and limits of the policy and the requirement to faithfully pay premiums on time. For the insurance provider, the requirement is to collect each premium in good faith in order to ensure the policy remains active, and to provide the agreed benefits in a timely fashion once those benefits are required. Seems pretty simple. However, given the number of examples of bad faith insurance claims in the long-term care insurance sector it appears as if actual receipt of benefits in a timely fashion is not guaranteed to reflect the timely payment of premiums. Long-term care insurers refuse to pay benefits for a variety of reasons. The language of the policy is the guide for determining the merits of a denial and how to challenge it. For example, older policies often narrowly define eligible care providers. If a caregiver does not meet the definition, the claim will be denied, but there may be grounds for appeal. Another common reason for denying benefits is a conclusion that the covered individual has failed to establish that he or she cannot perform two or more “activities of daily living," as defined under the plan. To successfully overturn a denial, the IKOR RNPA uses their experience, and works with medical providers, family, and caregivers to develop a detailed “plan of care around the activities of daily living" that supports the need for the services provided under the policy. So, if you feel your claim or your loved one's claim has been unfairly denied contact our office. We are experienced in dealing with denied insurance claims. We can help you sort through the policy, complete the need paperwork and assess the circumstance to gain approval of your long term care policy when it is warranted. Through our process and detailed assessment we can determine if the insurance company is acting in Bad Faith. If after completing our processes we will tell you if you could consider filing a lawsuit against your long term care insurance provider, but most of the time our involvement leads to an approved claim which is really the outcome our clients are usually seeking.

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