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Long-Term Care Insurance Denials Lawyer

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Insurance Claim Denied? Wallace Law is On Your Side

Long-term care insurance is meant to offer financial safety as we plan for the uncertainties accompanying old age and sickness. People opt for such care to help improve their quality of life. It is meant to afford us more time to live safely and independently in our old age or while managing a disability or chronic illness. It can help cover the expenses associated with a qualified caregiver or family member (under some policies) facilitating assisted daily activities (ADLs) like dressing, bathing, eating, or getting in and out of bed.

Long-term care services are expensive compared to other insurance claims. A private room in a nursing home or long-term care facility can cost more than $83,000 per year, which is partly why insurers and adjusters carefully scrutinize every claim and look for reasons to deny them.

Watching a loved one in pain while simultaneously fighting a difficult and draining long-term care denial is not easy for anyone. At Wallace Law, we know all too well how long-term care denials are an unfortunate part of the insurance game. Battling an insurer only takes precious time away from helping your loved one get better, which is why sometimes, it is easier and wiser to bring in a long-term care insurance denials lawyer to fight for you instead.

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What Are the Different Types of Long-Term Care Services?

Long-term care services aim to help an elderly, sick, or disabled person live independently for as long as possible. It is estimated that four out of five 65-year-olds will need some long-term care during their remaining years. It is typical for family members to administer long-term care support, or for caregivers and nurses to ensure a dependent person can safely care for themselves.

Long-term care services are usually offered in the following settings:

  • Home Care: It is common for family members to assist a loved one with daily activities at home, for both short and long-term needs. Some insurance companies, however, do not cover for a non-licensed family member.
  • Nursing Home Care: Nursing homes offer personal care and medical services to individuals who cannot manage daily activities.
  • Assisted Living Facilities: These offer a long-term solution for people with a prolonged illness or disability who require daily medical attention and assistance with activities such as eating, dressing, bathing, and more.
  • Intermediate Care Facilities (ICFs): Individuals with a mental disability or declining health who need more care than the elderly can use their long-term care insurance to assist with services in an ICF.
  • Continuing Care Retirement Communities (CCRCs): CCRCs are a mix of independent living, assisted living, and skilled nursing amenities for seniors who are 62 years or older. As health issues progress, a person can transition to a different level of care and utilize their long-term care insurance to help with personal care, among other things.

What Are the Three Different Types of Long-Term Care Insurance Policies?

The care needed to support serious or ongoing health conditions and disabilities is typically not covered by traditional health insurance or Medicare. Long-term care insurance gives people a say in their care along with the financial means to pay for it. There are three types of long-term care policies to choose from:

  1. Traditional Long-Term Care Insurance: Traditional long-term care insurance affords potential policyholders options regarding the type of care and the place to receive such care, like at home or in a facility.
  2. Hybrid Long-Term Care Insurance: A hybrid long-term care insurance policy is part of a traditional life insurance policy and long-term care insurance. This option gives people access to death benefit funds for assisted care.
  3. Life Insurance With a Long-Term Care Rider: A long-term care rider allows a person to use part or all of their life insurance policy’s death benefit to pay for long-term care services while alive.

Long-Term Care Insurance Denial Cases on the Rise

Long-term care insurance costs depend on health, age, and coverage amount. People 55 to 65 years of age and older pay approximately $79 to $313 monthly to access long-term care services. However, many insurance companies make it challenging for policyholders to get paid after submitting a claim. A recent AHA study indicates health plan claim denials are on the rise. About 18 percent of in-network claims are denied on average, but some insurance plans deny up to 80 percent!

To the detriment of most policyholders who pay for the security of long-term care, insurance companies seem to be paying out far less than expected. Only one person in every 500 cases appeals the insurance company’s decision, which means too many people are leaving their rightful money behind. If you are dealing with unfair long-term care claims decisions or unethical insurance practices, this is your sign to do something about it.

Why Would Long-Term Care Insurance Be Denied?

Seeing a loved one in pain is tough, and a denied long-term care claim is a shared emotional and financial burden for the person who needs care as well as their family members.

Sometimes, insurers might deny claims for reasons such as clerical errors or mistakes, lapsed coverage, or payment issues. However, insurance companies may take up unethical claims practices to reject long-term care claims to wrongfully block a payout. Some of the common strategies used by bad faith insurance companies are:

  • Setting a higher threshold for chronically ill patients so they have more difficulty accessing coverage
  • Using medical-related excuses, requesting second or third opinions, or conducting additional scrutiny of health records to deny a payout after conditions have improved
  • Delaying payments by excessively requesting further paperwork or creating strict standards for qualified nursing homes
  • Citing insufficient documentation or errors to hinder approval

We take long-term care claim denials seriously, and our insurance dispute lawyers can help you and your loved one fight for your rights.

Policy Lapses

Some policyholders might miss out on paying their long-term care premiums because of old age or memory issues, which could disrupt coverage. With the help of our qualified lawyers at Wallace Law, you can argue cognitive impairment as a genuine reason for missed premiums and reinstate your lapsed policy.

Excluded Medical Conditions/Treatment Deemed Unnecessary

Long-term care insurance has limitations regarding certain medical conditions or unnecessary treatments. Coverage differs based on the specifics of the long-term care policy, but basic exclusions include pre-existing conditions like Alzheimer’s Disease, self-inflicted injuries, alcoholism and drug addiction, as well as non-medical assistance like housekeeping and meal prep.

More Paperwork Is Required

Insurers require policyholders to submit paperwork before they can process a claim. Requirements include a provider and policyholder statement, physician statement, nursing assessment and care plan, and authorization to release information. Insurers can only accept a claim if they have enough evidence, but asking for excessive or unnecessary paperwork is likely an unethical insurer’s way of stalling payouts.

Conditions Deemed Not Severe Enough or Some Improvement in Conditions is Shown

Some long-term care providers might not cover long-term care support for people who can perform ADLs like cooking, dressing, or using the bathroom, or are otherwise able to live independently. Similarly, your insurance claim might get denied if you show improvement from an earlier condition and can therefore, perform two or more daily activities.

Facility Licensure

Insurers ask that long-term care facilities be appropriately licensed, registered, and certified. Residence in a long-term care facility that does not meet an insurance company’s licensing standards might result in claim denials.

Bad Faith Insurance Practices

Most people do not know when they are victims of bad faith insurance practices. This is because insurance companies use a variety of unethical insurance practices to throw you off their scent and prevent a payout. Examples of bad faith tactics include:

  • Lack of proper communication from insurance agents
  • Failure to thoroughly investigate a claim
  • Excessive or unexplained paperwork requests
  • Agent changeover that delays the claims process
  • Offering a lesser settlement than the claim is worth
  • Misrepresenting policy language
A faraway shot of a person being carried in a stretcher

How To Appeal Long-Term Care Insurance Denials

Some insurance companies look for reasons to deny long-term care claims, usually at the expense of policyholders. Rather than struggle alone, consider appealing a denied insurance claim.

Review the Requirements to Receive Benefits and the Fine Print In Your Policy

To appeal a denied claim, you will want to re-examine the requirements of your policy, benefits, and the fine print to see if there is any discrepancy. It is a good way to check if your insurer has followed the contract or engaged in unethical practices.

File an Internal Appeal

You can always file an internal appeal if your long-term care claim gets denied. An internal appeal asks your insurance company to fully and fairly review its original decision. Sometimes, internal appeals can weed out mistakes such as clerical errors that result in claim denial.

File an External Appeal

External appeals use a third party to review the claim, which means the final decision is no longer up to the insurer. However, people rarely appeal denied claims as they believe the insurance company holds all of the power. This is simply not true.

Get Help From a Long-Term Care Insurance Lawyer

A long-term care insurance lawyer can make a big difference in ensuring your legitimate claim gets approved.

Given that bad faith insurers use many ploys to trap policyholders, it takes careful legal analysis, negotiation skills, and an overall sophisticated strategy to fight long-term care denials.

Schedule a Consultation Today With a Long-Term Care Insurance Denials Lawyer

Some insurers care more about profit than the needs and interests of the people who file legitimate long-term care insurance claims. Policyholders who cannot get their long-term care paid for are often stuck with expenses that cost tens of thousands of dollars, if not more. Denied claims are usually financially debilitating for those needing care, which is why we are here to stop unethical insurance practices.

Do not let bad faith insurers trick you into dropping your legitimate claim. Wallace Law will review your claim for free and help you understand your legal options. Contact us today to schedule a free consultation.


Long-Term Care Insurance Denials: FAQs

What is required for an insured to qualify for long-term care benefits?

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How do I fight a long-term care insurance denial?

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Secured for a $90,000 life insurance claim, originally denied.

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    Looking for the best attorney to assist you with your insurance dispute? Well, look no further you have found him! Justin Wallace IS THE BEST!!!!!!! If it wasn’t for him taking over our insurance denial for roof replacement & property damage due to massive hail storm, we never would have received reimbursement to cover our new roof and costs of our other property damage. Justin Wallace has the experience, knowledge, & tenacity to fight for your claim. I HIGHLY RECOMMEND you contact him for your insurance denial.

    Laura Pavwoski


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