You purchased insurance so you’d be cared for when you need it, and would not have to burden family or friends. You paid for the coverage for years, but when you need it, the insurer denied the claim. This happens too often, as insurers issued these policies not realizing what medical advances would extend life expectancies for a large segment of the population. Just because an insurer underestimated its liability in the future does not mean you should suffer. Bartolic Law has helped the insured and their families secure payment of Long-Term Care Insurance when the insurer refuses to pay. They often challenge you do not yet need sufficient assistance with enough Activities of Daily Living. Activities they challenge include:
Long Term Care Insurance usually requires you need assistance with two or more Activities of Daily Living to qualify for benefits. Some policies require you already incur the expense of residential or home health care, while others pay only for meeting the need for assistance with the Activities of Daily Living. Insurers often use either of these variations against you to deny payment. If you have to incur the expense first, they hope to delay issuing the decision in hopes you cannot afford to maintain the expense during the review. If the policy does not require you to hire the assistance or incur the expense, they often cite the lack of doing so as a reason you do not really need assistance with the Activities. Fighting these denials can be private and embarrassing. Rest assured; we have seen it all. We are not shy to show an insurer the private things with which you need help, how you need the help, and why.
Long Term Care Insurance is especially important for individuals with Alzheimer’s disease, dementia, and neurological and movement disorders like Parkinson’s disease and ALS.
When the same insurance company insures both Individual Disability Insurance and Long Term Care Insurance, and the insured has a disabling condition that does not yet trigger Long Term Care Insurance, the insurance company may be more likely to fight the disability claim in hopes you will not be able to keep paying the Long Term Care premium.
ADLs are fundamental self-care tasks that people perform daily. They typically include bathing, dressing, eating, toileting, transferring (moving from a bed to a chair, for example), and continence. For long-term care insurance, the inability to perform a certain number of ADLs (often two or more) without substantial assistance is a common trigger for benefits, indicating a need for long-term care.
Insurance companies deny long-term care claims for various reasons, including:
If your long-term care insurance claim is denied, you should:
Long-term care insurance policies generally do cover pre-existing conditions, but they often have a waiting period (typically 6-12 months, sometimes longer) after the policy’s effective date during which care related to a pre-existing condition may not be covered. It’s crucial to disclose all pre-existing conditions truthfully during the application process, as failure to do so could lead to a denial for misrepresentation later on.
Yes, long-term care insurance policies almost always have limits on how much they will pay out. These limits can be structured in several ways:
The elimination period (also called the waiting period) is a specific length of time that must pass after you become eligible for benefits and before the insurance company begins paying for long-term care services. During this period, you are responsible for covering the costs of your care. Common elimination periods are 30, 60, or 90 days, but they can be longer. A longer elimination period usually results in lower premiums.
If your long-term care insurance claim is unfairly denied, your legal rights may include:
Long-Term Care insurance policies are nearly always individually issued. When the insurer egregiously denies the claim, how you frame the communications is critical, as you may have a claim for vexatious and unreasonable denial, triggering a right to statutory penalties and attorney’s fees under § 155 of the Illinois Insurance Code. You can maximize your likelihood of pinning penalties and fees on the insurer by following the Bartolic Law Strategy for Success©. Treat the insurer like a customer, and always ask what you can do to help the insurer understand your claim better. Offer to give them any visual evidence. The more we show we tried to make the task of approving the claim easy, the more likely a court will see a denial or delay as vexatious and unreasonable.
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