Representing People With Denied Insurance Claims

Fighting for your long-term care benefits

On Behalf of | Feb 17, 2022 | Insurance Disputes

There is no doubt that at some point, most older Americans will need some type of long-term care. Getting assistance with basic activities as physical or cognitive functions begin to deteriorate will be a fact of life, and for this reason many seek long-term care options. Many people do not realize that Medicare does not cover long-term assistance outside of basic care right after a hospitalization, and Medicaid may not even be an option for those who do not qualify.

Residents of Oklahoma who choose private long-term care insurance (LTCI), however, may be surprised when they receive a claim denial. If you are sure that the claim is legitimate, then the insurance company may be acting in bad faith. When this happens, it is important to know what steps to take to set things right.

Typical reasons for denying a claim

LTCI policies often use a standard for determining if the policyholder is in need of long-term care. The individual must be medically proven to be unable to perform a minimum of two of six Activities of Daily Living, which are:

  • Mobility
  • Eating
  • Dressing
  • Toileting
  • Continence
  • Personal hygiene

The insurance company may decide that the policyholder’s condition does not meet the criteria for long-term assistance, or that they only require short-term care. It is essential when filing a claim to not only get a doctor’s opinion, but also an affidavit from the doctor stating that the care needed will last at least 90 days.

Another reason for a denial happens when insurance company does not accept the policyholder’s Plan of Care or the facility they have chosen, according to its definition of what a nursing home is. It is also important for the policyholder to be aware of what the policy’s limitations are on the kind of facility covered and the type of services provided, as well as the waiting periods for eligibility for LTCI according to the terms of the policy.

What to do after a claim denial

Long-term insurance policies generally have an appeals process that requires an adherence to strict deadlines. When filing an appeal, it is essential to have all medical reports and relevant documents, and to file the proper forms within the deadlines. If the insurance company is unreasonably denying your claim, it may be necessary to pursue a bad faith insurance claim.