Common Reasons Long-Term Care Carriers Deny Claims

J.P. Gonzalez-Sirgo
Founder of J.P. Gonzalez-Sirgo, P.A.

Long-term care insurance coverage can be very important if a policyholder requires assistance because of illness or a severe injury.  The cost of assisted living or nursing home care can be staggering.  The average cost of a year in an assisted living facility in Florida is projected at nearly $38,000 annually while the annual cost of nursing home care is estimated at between $87,600 and nearly $97,000 per year, depending on whether the resident is in a private room.  Many people have the foresight to purchase a long-term care policy to cope with these astronomical expenses.  Unfortunately, some policyholders experience shock when their insurer refuses to provide coverage under the policy for which the insurer readily accepted insurance premiums.  Below we discuss a few examples carriers use to minimize payouts on claims.

Overly Burdensome Requests for Documents

When a policyholder files a claim, the insurance company will request certain documents which might include the following:

  • Medical Records: These records are needed to document the disabling injury or medical condition that constitutes the basis of the claim.  Since medical documentation of the disability is necessary to evaluate the claim, this type of request is proper unless it is repetitive.
  • Tax Returns/Income Records: Since the insurance carrier’s obligation to pay these benefits is directly affected by an insured’s ability to work, the insurer might request financial documents periodically.  Like medical records, this type of request is legitimate provided the request does not seek information that is duplicative or irrelevant. 

A tactic insurers often use involves sending multiple requests for information based on the claim that the original response was not received or was on the wrong form.  The purpose of these burdensome requests is to discourage a claimant.  The insurer recognizes that many policyholders get frustrated and give up or accept an undervalued settlement.  If your insurance company is asking for information or records that do not seem relevant or that you have already provided, you should seek out the advice of an experienced Florida insurance long-term care claims attorney.

Asserting the Insurer Is Not Cognitively Impaired

While other triggering provisions of long-term care policies tend to focus on physical capacity, this provision of a long-term care policy addresses impaired cognitive abilities.  Benefits are paid under this provision if an insured needs direction or supervision because of cognitive limitations.  This loss of intellectual capacity usually is defined as requiring a continual need for supervision to avoid harm to the insured or others.  This impaired cognitive ability often will be based on standardized testing or clinical evidence that measures abstract or deductive reasoning, memory, and orientation regarding time, location, identity, and time.

A common strategy that insurance carriers use to deny coverage on this grounds is to focus on language like “continual supervision.”  The insurance company will point out that the insured does not need supervision 24/7.  However, this narrow reading is inappropriate because it would essentially permit every claim involving cognitive capacity to be denied.  The term “continual” generally is read as “intermittent” not “constant.”

Another strategy used by insurance companies when evaluating claims involving mental impairment involves focusing on “testing” instead of a physician’s medical opinion.  Many people perform flawlessly on standardized testing of mental capacity despite an evaluation by their physician finding that they need assistance and supervision to ensure their safety.  Policyholders can challenge an insurance company that ignores medical assessments while relying entirely on standardized testing.

Our Miami insurance claims 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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