Common Questions About Long-Term Care Insurance and Claims Disputes [Part II]

This is Part II in our multi-installment blog post discussing long-term care and challenges facing policyholders pursuing claims under such a policy.  In Part I, we focused on the different types of care for people disabled by an injury or illness, and how long-term care policies and Medicare provide coverage for those who need supportive care.  Part II focuses on other common questions about long-term care (LTC) insurance.

When do long-term care benefits under a private insurance policy become available?

LTC policies deviate significantly in terms of how the right to benefits is triggered.  Some of the factors that might make you eligible for care include:

  • Impaired cognitive or mental functioning
  • Inability to engage in a number of activities of daily living (ADLs) without assistance.  The specific policy will define the relevant ADLs, but it might include use of the bathroom, getting in and out of bed, handling nutrition and hydration needs, and similar types of daily activities.  The policy will indicate the specific types and number of ADLs that qualify an insured for coverage. 
  • Hospitalization for a minimum of three consecutive days
  • Care specifically ordered by your physician

Although every LTC insurance policy differs to some extent, most policies carry one or more provisions similar to those above.  The more clear and specific the policy language, the less grounds for coverage disputes.

Who determines if a policyholder qualifies for LTC benefits?

The party that determines eligibility for benefits can be a vital consideration, so any application for LTC insurance should carefully review a prospective policy before making a purchase.  The best practice is to select a long-term care policy that authorizes benefits when ordered by the policyholder’s treating physician.  Predictably, your own physician provides a better option for a gatekeeper to benefits than a doctor selected by the insurance company.  The insurance company doctor has a direct financial interest in minimizing payouts from the insurance company.

When does coverage under an LTC policy commence?

While the existence and duration of a waiting period will depend on the individual policy, most LTC coverage imposes a mandatory waiting period between the time an insured is found to be medically eligible and the time benefits commence.  Although it is important for policyholders to understand when policy periods are triggered under their policy, standard waiting periods range from 20 to 100 days.  The insured is financially responsible for care during the waiting period whether rendered at a nursing home, assisted living facility, or in-home.  Although there are policies that do not impose a waiting period, the expense associated with purchasing this form of coverage will be higher.

Because waiting periods can vary dramatically, policyholders should carefully review a prospective policy.  The calculation of the period might differ in terms of being based on consecutive days or cumulative days with breaks in between stays in the nursing home.  Further, some policies impose a single waiting period over the life of the policy while other LTC coverage imposes a new waiting period every time the insured attempts to seek benefits under the policy.  In still other situations, the independent waiting period will be based on claims made within a certain period of time, such as six months or a year.

How do I initiate the claims process?

Claimants must understand the process of commencing a claim before suffering an injury or illness to avoid inadvertently running afoul of a technical term under the policy.  The initiation of a claim involves submitting written notice of the claim to the insurer.  The insured also should provide or make available appropriate medical records and a proof of loss form, which will be provided by the insurance carrier.

Our Miami long-term care insurance law firm invites you to contact us if you are having difficulties with your insurance company.  Florida insurance claims lawyer J.P. Gonzalez-Sirgo handles claims against insurance companies in Miami and throughout Florida. The Law Firm of J.P. Gonzalez-Sirgo, P.A. offers free consultations and case evaluations.  No Recovery, No Lawyer Fees.  Call 305-461-1095 or Toll Free 1-866-71-CLAIM.

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