When it comes to long-term care insurance policies, elderly people need them the most because they can provide in-home services for activities of daily living (ADLs). Some policies will provide for assisted living facilities or nursing home care.
You can purchase long-term care insurance for yourself or to help an aging loved one with a disability, chronic illness, cognitive impairment, or because they need help engaging in ADLs. These policies cover more than a typical health insurance policy or Medicare.
However, the insurance company could deny your claim, and you’ll likely want an insurance attorney to help you get the approval you need.
What Determines Eligibility for Long-Term Care Benefits?
Every insurance policy is different, but it will detail the benefits it provides. These contracts may include a medical necessity or detail an inability to perform two or more of the activities required for daily living. These include an inability to dress, bathe, prepare food, or clean the house.
Coverage may also be based on cognitive impairment, and it must be proven that these impairments prevent the claimant from performing certain living activities. However, a physician needs to sign off on these impairments, then a care provider must be recommended to meet those impairment needs.
What Happens After Submitting a Claim?
Insurance companies will usually perform an in-person assessment with a licensed healthcare provider. This assessment is used to determine the eligibility of your claim. However, there may be ambiguity in the situation, which could lead to a denial of the claim.
Problems with paperwork, missing documents, and other little details may be holding you or a loved one back from the coverage you need. Because of the language of these contracts, it takes someone with a background in insurance law to help navigate the road ahead.
Common Reasons for Claim Denials
In addition to paperwork mistakes, there are many reasons why long-term care coverage may be denied. You may have made a late payment or missed one altogether. You could have selected a long-term care facility that isn’t an eligible care provider for your coverage.
Some long-term care policies also require prior hospitalizations, while others may not cover you if you can perform some limited activities of daily living. In other cases, conflicting medical opinions may hold you back from approval of your claim, or your medical condition may be excluded.
Why You Should Work with a Long-Term Care Insurance Claim Attorney
A long-term care insurance claim attorney can help you when you’ve received a denial of your claim. They have a background in the regulations of these policies and can provide sufficient evidence that your condition limits your abilities to perform ADLs.
If you have been denied your claim, sit with an attorney for a free initial consultation to discuss your insurance policy and learn about your options.
