Long-term care insurance provides a critical financial investment in the event that an individual suffers a debilitating injury or illness that requires extensive medical care over a prolonged period. The cost of nursing home care can be staggering which makes this form of coverage appealing. Unfortunately, many people who exercise the foresight and judgment to purchase this type of coverage find that their insurer does not live up to its promises when a claim is filed. The failure of an insurer to honor this type of claim can both pose devastating financial obstacles and create difficulties in obtaining needed medical care. This blog discusses one of the most common grounds used to deny a claim under a long-term care policy – lack of medical necessity.
The term “medical necessity” refers to a somewhat nebulous and complex concept that makes it ripe for manipulation by insurance companies attempting to deny a claim. One reason the concept of medical necessity can be difficult to pin down is that it often refers to the particular insured as much as the diagnosed medical condition. Put another way, a particular medical treatment might be necessary for a particular individual with a specific condition but not necessary for another individual suffering with the same ailment.
Policies vary dramatically in the way they define the term “medical necessity” with some policies defining the term very specifically and others using a broader definition. A very specific definition might read something like “A service or supply ordered by a physician that is customarily recognized by those in the medical profession as an appropriate treatment for the insured’s particular medical condition or injury and neither experimental or educational.” By contrast, a more general definition might involve something like the following: “The service or supply cannot be forgone without negatively impacting the insured’s condition.” Regardless of whether the policy uses a general or specific definition, the term will be open to interpretation by the insurance carrier looking for a rationale to deny a costly claim.
If you have concerns that your long-term care insurance provider might deny your claim because of a lack of medical necessity or some other grounds, one strategy is to contact your insurer for pre-approval of the medical treatment or procedure. While prior approval does not provide an absolute assurance of coverage, the task of obtaining coverage will be eased with a pre-approval. Further, potential objections based on lack of medical necessity or other grounds can be addressed prior to performance of a procedure that the insurer ultimately might not cover.
When a lawyer is retained by an insured with a long-term care claim that has been denied, the lawyer can provide assistance in the following ways:
- Retaining experts to attest to the medical necessity of the procedure or treatment
- Gather sworn statements, letters, affidavits, and medical records as proof
- File a lawsuit for breach of contract and/or bad faith
- Identify ambiguity in the relevant provision which must be construed against the insurer
If your insurance carrier is refusing to comply with its contractual obligation, you are invited to contact our law firm to speak to an experienced Miami insurance claims attorney. My law firm specializes in representing policyholders in claims disputes in Miami and throughout Florida. Click here to read about some of our case results. 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.