Why Was My Loved One’s Long-Term Care Insurance Claim Denied?
As we age, our chances of needing long-term care increase—and about 53% of us will need some form of long-term care for more than a year. In 2020, the average cost of a private room in an Illinois nursing home was $84,312. In the greater Chicago area, it cost $102,384.
Even if you have significant assets, these costs might seem unmanageable. That is why many people invest in long-term care insurance to help reduce this financial burden.
When the insurance company denies your loved one’s long-term care claim, it can feel like a violation of trust. After all, your family member has spent a considerable amount of money for this policy, only to be denied help when they need it most.
Our attorneys help people get the coverage they deserve, using practical, client-centered strategies and aggressive tactics. In this article, we explore long-term care denials and suggest ways you can improve your chances on appeal.
What Is Long-Term Care Insurance?
Some people are surprised to discover that Medicare will only pay for 100 days of skilled care. If your loved one’s need for care extends beyond that time, they will either need to pay the bill or qualify for Medicaid.
If you have significant assets or income, it is unlikely that you will qualify for Medicaid. Many middle-income and upper-income individuals purchase long-term insurance policies that step in and cover some of the costs of skilled nursing care, assisted living, at-home care, and even adult day care.
Long-term care insurance is typically sold by for-profit insurance companies like Mutual of Omaha and UNUM. These policies can vary dramatically. Some offer comprehensive coverage that pays for in-home, dementia, skilled nursing, and assisted living services, while others strictly limit coverage and have broad exclusions.
When someone with long-term care insurance no longer can live independently, they can file a claim. However, many families run into unexpected difficulties.
5 Reasons Why the Insurance Company Might Deny Your Long-Term Care Claim
The Facility or Caregiver Is Not an “Eligible Care Provider”
Long-term care insurance companies are very particular about who can provide covered services. Your loved one’s policy will probably only pay for services from an “eligible care provider.” Typically, these individuals and facilities are state-certified professionals.
Before you apply for long-term care benefits, it is a good idea to carefully review your policy’s language. If you request payment for services provided by a caregiver or facility that does not meet its criteria, the insurer will probably deny the claim.
Another possible stumbling block involves eligible care providers and waiting periods. For example, some long-term care policies’ waiting periods do not start until your loved one is consistently receiving care from a trained professional, and you will not get credit for similar services that a spouse or family member provided.
Your Loved One Can Still Perform Some Activities of Daily Living
To qualify for long-term care benefits, you typically must be unable to care for yourself independently. Many policies insist that you are unable to perform at least two out of six essential activities of daily living (ADLs).
These activities include:
- Bathing and grooming
- Dressing yourself
- Feeding yourself
Sometimes, insurance adjusters will argue that your loved one can still perform basic ADLs, even though they struggle with them and might be unsafe living alone.
In these cases, a long-term care attorney can help you document your family member’s difficulties and need for skilled care. However, please note that some policies will not cover certain personal services, like light housekeeping, running errands, or social companionship.
There Are Exclusions and Limitations in the Policy’s Fine Print
If your loved one’s long-term care insurance policy was written decades ago, you might be surprised about what it contains (and what is missing). Many older policies are very limited in their coverage and might include exclusions and limitations that seem impractical.
- Outdated language: Many older policies limited coverage to “nursing home care,” which is vaguely defined. Sometimes, insurance companies will argue that these policies do not cover more modern long-term care services, like dementia care, assisted living, and home health care.
- Waiting periods: Different waiting periods might apply to different types of care. For example, some policies will have shorter elimination periods for in-home care, but make your loved one wait for 90 calendar days before they cover inpatient care. Even worse, some policies will not cover care until your loved one has received reimbursable services for 90 days—so even if they qualified for care earlier, you still must wait.
- Excluded conditions: There might be limitations and exclusions for specific conditions, like self-inflicted injuries or substance abuse. It is also common for long-term care policies to deny coverage for pre-existing conditions if you require skilled care within six months of purchasing the policy.
- No prior hospitalization: In the past, many policies included a “gatekeeper clause,” and would not cover nursing care unless your loved one was hospitalized beforehand. However, Illinois now prohibits these clauses.
The Insurance Company’s Doctors Think Your Loved One Is “Just Fine”
Doctors can disagree about the severity of someone’s needs and conditions. Unsurprisingly, the insurance company’s doctors often side with them, arguing that your loved one does not require long-term care. This is especially common in cases that focus on Alzheimer’s disease, dementia, and cognitive impairments.
When this happens, you will need strong medical evidence, including medical records, care notes, and diagnostic testing. Our attorneys frequently consult with treating doctors and other experts, documenting our clients’ precise diagnoses and limitations.
Your Loved One Did Not Pay Their Premiums
As people’s health and abilities decline, they often make mistakes. This can include neglecting to pay their bills. If the insurance company denies your loved one’s long-term care claim because of a missed monthly payment, you should immediately consult with a lawyer.
What Should You Do After an Insurer Denies Your Long-Term Care Insurance Claim
You should never assume that the insurance company’s long-term care insurance denial is correct. Long-term care is expensive, and companies are always trying to save money. Many insurers will dispute claims that they should legitimately cover, hoping that the policyholder will simply give up.
As soon as you receive a denial, you should contact a long-term care lawyer. They can help you interpret your loved one’s policy and assess your legal options. We might discover that they are owed long-term care insurance benefits and will suggest ways you can move forward.
Bryant Legal Group: Respected Long-Term Care Attorneys in Chicago
Bryant Legal Group has earned a reputation as one of Illinois’ premier disability and long-term care insurance firms. We have helped people across the state navigate their complex insurance claims and lawsuits.
We take a client-centered approach that is practical, sophisticated, and aggressive. If the insurance company denied your loved one’s long-term care insurance claim, please contact our office for a free consultation. We can help you understand your legal options and rights.
Cost of care survey (2021, February 12). Genworth. Retrieved from https://www.genworth.com/aging-and-you/finances/cost-of-care.html
215 ILCS 5/351A-5. Retrieved from https://www.ilga.gov/legislation/ilcs/ilcs4.asp?DocName=021500050HArt%2E+XIXA&ActID=1249&ChapterID=22&SeqStart=96900000&SeqEnd=98500000
215 ILCS 5/351A-6. Retrieved from https://www.ilga.gov/legislation/ilcs/ilcs4.asp?DocName=021500050HArt%2E+XIXA&ActID=1249&ChapterID=22&SeqStart=96900000&SeqEnd=98500000
Stark, E. (2018, March 1). 5 things you should know about long-term care insurance. AARP. Retrieved from https://www.aarp.org/caregiving/financial-legal/info-2018/long-term-care-insurance-fd.html
The content provided here is for informational purposes only and should not be construed as legal advice on any subject.