Articles Posted in LongTerm Care Insurance

Insurance denial, ERISA denial, claim denied
Every insurance policy requires that you give notice of your claim for benefits to the company before benefits can be paid.  It doesn’t matter if the claim is for medical services, disability benefits, life insurance, fire, flood, theft, etc. Obviously, notice and information about your claim is necessary before the insurance conpany can process and pay the claim. Policies also usually require that notice of a claim be given within a specified time period following the loss, for example, “30 days,” or “as soon as practicable,” or “as soon as reasonably possible,” etc.  Again, this is fair because evidence related to the claim is fresh, and most readily available nearer the time of the event.

But, what happens if you can’t, or don’t comply with the policy notice requirement?  What happens if don’t give notice until months, or even years after your claim accrued?

Good questions.

On January 13, 2017, the Los Angeles Times published a column entitled Healthcare insurance hell: If at first your claim is denied, try, try again

The article describes on insured’s extreme difficulty in obtaining approval for treatments of her multiple autoimmune disorders that cause chronic pain, migraines, extreme dizziness and debilitating chronic fatigue. As the title shows, the main thrust of the argument is to never give up if your health insurance claim is denied – however, this advice is not only applicable to health insurance claims – the same holds true, believe it or not, for Long Term Disability, Long Term Care, and even Life Insurance claims!  

Some interesting additional information is also included in the column:

As part of Kantor & Kantor’s”Throwback Thursday”, we take a look at Mondolo v. Unum Life Ins. Co. of Amer., CV-11-07435 CAS (MRWx) (C.D. Cal. 2013).

Kantor & Kantor LLP achieved a victory on behalf of client Tanya Mondolo, who sued Unum Life Insurance Co. in U.S. District Court for the Central District of California for wrongfully denying her disability insurance benefits. The court ruled that Unum, a Fortune 500 company and the largest group and individual disability carrier in the United States, abused its discretion in terminating Mondolo’s disability benefits. The court ordered Unum to reinstate benefits, with interest, and that Kantor & Kantor could make a motion for attorneys’ fees and costs.

Mondolo suffered from fibromyalgia and avascular necrosis, often called bone death. Her physicians believed the bone death was a late developing side effect from the chemotherapy regimen used years ago to treat her leukemia. She had difficulty walking, suffered from uncontrolled pain, and was too weak to tolerate prolonged sitting or typing.

Kantor and Kantor LLP was nominated and has now been awarded the 2015 Best of Business Award for the Small Business category.

The Small Business Community Association has been dedicated to empowering and recognizing small business owners who make a difference in their respective communities since 2006.

We are honored to accept this award and grateful that our firm is recognized in this way.

Kantor & Kantor is honored to announce the selection of four attorneys from the firm for the 2015 Southern California Super Lawyers list. Inclusion in this list is reserved for attorneys who exhibit distinct excellence in their practice.

Super Lawyers, a prominent attorney rating service, identifies exceptional lawyers from more than 70 practice areas. The selected attorneys have attained substantial peer recognition and widespread professional achievement. The extensive and multiphase process used to determine 2014 California Super Lawyers relies on peer nominations, evaluations, and independent research.

All four lawyers were selected for their successes in representing people denied disability – particularly those with disabling conditions such as eating disorders, autoimmune diseases, Alzheimer’s, Parkinson’s, Multiple Sclerosis, cancer and mental illness – as well as assisting people recover benefits under long-term care, health and life insurance policies. This recognition and honor demonstrates the talent, dedication, and diligence of these attorneys; all of which they utilize to obtain the insurance benefits to which their clients are entitled.

Lupus is a chronic, autoimmune disease that can damage any part of the body (skin, joints, and/or organs inside the body). Chronic means that the signs and symptoms tend to last longer than six weeks and often for many years.

In lupus, something goes wrong with your immune system, which is the part of the body that fights off viruses, bacteria, and germs (“foreign invaders,” like the flu). Normally our immune system produces proteins called antibodies that protect the body from these invaders. Autoimmune means your immune system cannot tell the difference between these foreign invaders and your body’s healthy tissues (“auto” means”self”) and creates autoantibodies that attack and destroy healthy tissue. These autoantibodies cause inflammation, pain, and damage in various parts of the body.

Lupus is also a disease of flares (the symptoms worsen and you feel ill) and remissions (the symptoms improve and you feel better). These are some additional facts about lupus from the U.S Department of Health and Human Services, Office on Women’s Health:

Congratulations to Kantor and Kantor LLP who won the Small Business Community Association 2015 Best of Business Award for the Small Business category.

We are honored to have our work recognized in this way. Our attorneys and support staff work tirelessly to help those in our community get the benefits paid to which they are entitled. Medical Insurance, Disability Insurance, Long-term Care Insurance and Life Insurance are paramount to the health and longevity of those in our community. When Insurance companies fail to honor their contractual obligations to pay benefits under these policies, it is a detriment to our community.

We are grateful that our clients trust us and know that we get their benefits paid so they can continue to live healthy, fulfilling lives.

Every day we are asked similar questions by our clients and prospective clients. They typically revolve around such themes as”how can my insurance company blatantly refuse to pay?””Why is it that I have to engage a lawyer to fight for my benefits when my doctor has clearly proved that I am disabled?” And,”why can I only sue for the benefits I am owed and no punitive damages?”Unfortunately, we live with a system where insurers can, and do, deny disability claims that should be paid. Lawsuits are often necessary. Even then, people who need insurance benefits most can sometimes wait up to two years before their case goes to court or settles.

The Employee Retirement Security Act (“ERISA”), which is the law that governs most GROUP insurance policies, is stacked in favor of the insurance companies. ERISA imposes significant procedural limitations on the enforcement of group insurance benefits, and limits those benefits to those provided for in the policy. No emotional distress. No punitive damages. No out-of-pocket or consequential damages. And, attorneys fees only at the discretion of the Court. Employer Sponsored Group Policies fall under the Act unless they are a Government or Church Plan. ERISA is a federal body of legislation that establishes minimum standards for retirement, health, and other welfare benefit plans offered by employers to their employees. The Act expressly preempts all state legislation “relating to” an employee benefit plan, and federal courts have interpreted that phrase broadly, finding that a state law “relates to” a benefit plan “if it has a connection with or reference to such a plan.” The Act’s pre-emption clause extends to any state law allowing for recovery under an applicable plan. Unfortunately, this has resulted in a situation where ERISA preempts all common law tort actions for bad faith insurance and, consequently, does not allow plaintiffs to collect extra-contractual or punitive damages on claims involving covered insurance plans.

So what does this mean for the insured and the insurance company? For the insured it means that if they are denied health or disability benefits and they sue the insurance company under ERISA, the most they can hope for is that their benefits will be reinstated and back-paid to the time that they were denied; and that their attorney’s fees will be reimbursed in whole or part.

As one of the few firms in California who handle long term care disputes, Kantor & Kantor frequently sees long term care claims which were denied on the basis that the facility or caregiver were not “eligible” under the Policy. One of the reasons for frequent denials is that the long term care policies sold in the 1990’s were written before the popularity of”assisted living facilities.” As a result, policyholders try to use their policies to cover the cost of room of board in an assisted living facility, when the policy may only provide benefits for a stay in a “licensed” nursing home.

An article in Money Magazine suggested that long term insurance is a valuable investment. It cites lower statistics for those who may need care in the future: 44% of men and 58% of women may ultimately need long term care of more than 3 months. Other statistics have suggested that up to 70% of the population may require long term care in their lives. Regardless, the article suggests that the insurance may be a worthwhile investment since it is meant to protect against catastrophic events.

If you have long term care insurance, you can take steps to make sure that it works for you. Many insurers who issued policies in the 1990’s no longer underwrite long term care insurance policies. However, if you have a policy which was issued by an insurer who is currently in business, such as Genworth or Bankers, you should contact your agent to ensure that your policy is up to date. Specifically inquire whether your policy will provide coverage for a stay in an assisted living facility. If you are assured that there is such coverage, ask for confirmation in writing.

If you suffer from certain medical conditions, including Multiple Sclerosis, Complex Seizure Disorder, Dementia to name just a few, you likely also suffer from cognitive impairment which can affect your ability to perform the duties of your job. If your illness, or the cognitive decline associated with that illness, makes it impossible for you to perform in your job, you might be able to access the benefits of a Long Term Disability Policy. Such policies are often provided to employees through their employer benefits plans, or might be acquired individually. If you become disabled and make a claim for disability benefits based on cognitive issues, it is extremely important to document the cognitive impairment you suffer. Neuropsychological testing is one excellent way to document that cognitive impairment.

Your neurologist may order this testing as a routine part of your care. If that has happened, you should consider using the test results as part of the evidence you provide to your disability insurer. If that has not already happened, we strongly recommend you get this testing done to support your claim. Note that if your neurologist orders the testing as part of your treatment and care, your medical insurance may cover the cost, which is high. If, however, you have the testing done on your own or through your attorney, insurance most likely will not cover the cost as it is forensic testing – testing to provide evidence.

Not all neuropsychologists understand the intricacies of documenting cognitive impairment to support a disability claim. Make certain that the neuropsychologist you see has a good reputation and plenty of experience performing the testing and preparing comprehensive written reports.

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