Long-Term Care Insurance Claims

Long-Term Care Insurance Claims

Long-term care (LTC) typically pays for daily support for those with disabilities, illnesses or cognitive impairments. These policies provide coverage to people who need assistance from another person with their activities of daily living, or because of mental deterioration (“cognitive impairment”) that can be caused by Alzheimer’s Disease, other mental illness or brain disorders. LTC policies pay benefits if (1) a person becomes “chronically ill”, and (2) the necessary services are prescribe in a written plan of care. A person will be considered “Chronically Ill” when one of the following occurs:

1. A person is unable to perform, without Substantial Assistance, at least two Activities of Daily Living for an expected period of at least 90 days due to loss of Functional Capacity; or
2. A person has a Severe Cognitive Impairment requiring substantial supervision to protect against threats to his or her own health and safety.

The six standard activities of daily living (ADLs) are generally recognized as bathing, dressing, toileting, transferring (getting in and out of bed or chair), eating, and continence. Activities of daily living are the most common triggers used by insurance companies to determine eligibility for long-term care insurance benefits.

Depending on the policy language, most policies will provide a maximum daily or monthly benefit for reimbursement of expenses incurred for the following types of care: nursing home care; assisted living facilities; in-home care; home modifications; adult day care services respite care. Because some long-term care policies reimburse policyholders for only certain forms of care, it is important for a person to understand the terms of their policy. Long-term care may be divided into three levels:

Skilled care may be continuous round-the-clock care designed to treat a medical condition; it is ordered by a doctor and administered by skilled medical workers, such as registered nurses or professional therapists, as part of an established treatment plan;

Intermediate care is intermittent nursing and rehabilitative care provided by registered nurses, licensed practical nurses, and nurse’s aides under a doctor’s supervision;

Custodial care helps the patient perform ADLs; it can be provided by someone without professional medical skills, but it is supervised by a doctor.

The most common long-term care claims involve a person who needs a caregiver that comes to their home to provide stand-by or hands-on assistance with their activities of daily living. The caregiver and/or the insured record the time that at caregiver spends each day providing in-home care, and records the services provided, and the time sheets are ultimately submitted to the LTC carrier for reimbursement. A caregiver’s time can also be tracked by having them log into a service like Care Exchange, which allows a caregiver’s time and services to be verified by the carrier on-line.

Long-term care claims get denied for a variety of reasons. Here are some of the most common reasons long-term care claims get denied:

• Insufficient Evidence Provided by the Insured: Long-term care insurance claims get denied because the policyholder provides the insurance company with insufficient evidence or documentation. If the policyholder provides the insurance company with poor or insufficient medical records, the claim will be denied. For a claim to be approved, the policyholder must make sure that they have provided enough supporting evidence to prove their claim eligibility.
• Lapse in Payment of Premiums: An accidental policy lapse can occur when a policyholder suffers from a cognitive impairment and/or a sudden health crisis. If the insured can no longer manage their financial affairs due to a cognitive impairment and/or sudden health crises, this can result in missed premium payments and eventually a lapse in coverage. One way to avoid a potential lapse is to name a third-party addressee. The third-party addressee will be notified of any gaps in premium payments. In California, Insurance Code §10235.40(a) provides that an individual long-term care policy shall not be issued until the person applying for insurance has been given the right to designate at least one individual, in addition to the applicant, to receive notice of lapse or termination of a policy for nonpayment of premium. California Insurance Code §10235.40(c) provides that individual long-term care policies shall not lapse or be terminated for nonpayment of premium unless the insurer, at least 30 days before the effective date of the lapse or termination, gives notice via First-Class mail to the insured and to the individual or individuals designated to receive notice by the policyholder.
• Care Provided by a Family Member: Whether the policy covers care services provide by a family member depends on the policy language. Some policies do cover family caregivers, but they might have certain restrictions. Each policy varies, so it is important for the policyholder to read their policy.

How Can Law Offices of Kevin M. Zietz Help with a Denied Long-Term Care Claim?

Attorney Kevin M. Zietz consults with potential client about their long-term care policy, and the claims process. We can help people gather the necessary information to apply for long-term care benefits if a claim has not yet been presented.

If a claim has been made and denied, Law Offices of Kevin M. Zietz can handle the claim at the appeal stage of the claim. There are usually time limitations on the how long the policyholder has to submit a formal written appeal so policyholders should consult with an attorney at the earliest possible time following a claim denial.

If a claim is denied on appeal, Law Offices of Kevin M. Zietz can file a lawsuit against the insurance company and pursue a case for breach of contract and breach of the covenant of good faith and fair dealing (bad faith), and any other causes of action that are appropriate given the circumstances of the case.

Attorney Kevin M. Zietz is able to assist policyholders with their long-term care claims from the inception of their claim through jury verdict if necessary. Call Law Offices of Kevin M. Zietz for a free consultation if problems are encountered when pursuing a claim for long-term care benefits.