LONG-TERM CARE INSURANCE APPEALS
An individual turning 65 today has a nearly 70% chance of requiring some type of long-term care services in the future. Yet, when it comes to long-term care, it seems as though good solutions are hard to find. Long-term care insurance premiums have continued to increase, as insurers, perhaps, have become more realistic about pricing their policies.
Long-term care insurance is typically sold by for-profit insurance companies. These policies can vary drastically. 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 can no longer live independently, they can file a claim to receive the benefits of their policy. However, many families run into unexpected difficulties.
Increasingly, we are seeing clients who have spent years paying into a policy, only to be denied help when they need it. When a claim is denied, the insurer provides a basis for the denial. The two most common reasons for denial are:
The Facility is not an “eligible care provider”
Long-term care insurance companies are extremely particular when it comes to defining ‘providers’. Each policy specifically defines the requirements for who can provide covered services. It is a good idea to carefully review the language in this section of your policy. Oftentimes, this basis can be rebutted using various Washington RCW’s.
2. The insured does not meet the requirements for Activities of Daily Living or Cognitive Impairment
To qualify for long-term care benefits, many policies require that you be unable to perform a certain number of activities of daily living (ADLs). Sometimes, insurance providers will claim that your loved one can still perform basic ADLs, even though they struggle with them and might be unsafe living alone. Sometimes they will go as far as to claim that your loved one with severe dementia does not actually have cognitive impairment.
These activities include:
Bathing and grooming
Dressing yourself
Feeding yourself
Continence
Toileting
Mobility
These decisions can be appealed. Strategies for dealing with a denial of long-term care benefits vary depending on the basis of denial. If you believe that benefits should be paid under the policy, you should not allow the insurer to merely deny the benefits without submitting an appeal.
