A Long Term Care Insurance Claim denial can be a frustrating and exhausting process for all involved. Below are five common reasons insurance companies deny claims, and tips on how to steer clear of denials.
Denial Reason Number 1: “The care was not provided by an eligible care provider.”
Prior to retaining a caregiver or choosing a long term care facility, investigate whether the Policy has certain licensing requirements. In addition, states may have different licensing requirements, so the Policy’s licensing requirements may not pertain to your state. Be mindful of all these requirements when selecting a facility or caregiver.
Denial Reason Number 2: “The care was not appropriately documented.”
Home Health Care and Facility Care Providers should keep detailed daily notes of the care and assistance actually provided. Make sure you use an agency or care-giver who agrees to make this part of the service.
Denial Reason Number 3: “The Policy has lapsed.”
Most policies have protections to prevent and inadvertent lapse of coverage. Consult a knowledgeable attorney immediately in the event of a lapse notice.
Denial Reason Number 4: “The insured did not require assistance with 2 or more Activities of Daily Living. “
This is usually due to faulty paperwork and not the actual needs of the insured. Check all claim forms submitted by the attending physician and the caregiver prior to submission to ensure that they have been appropriately completed and provide ample detail.
Denial Reason Number 5: “Benefits are not payable while the insured lives in an Assisted Living Facility.”
This reasoning is predicated on a belief that an Assisted Living Facility is not an insured’s “home.” This may be contrary to express policy language or state laws which may require coverage under these circumstances.
For over 20 years, our lawyers have been in the business of making sure people get the insurance benefits they have paid for. We have successfully prosecuted many long term care lawsuits, and some have resulted in multi-million dollar settlements.
All of the Long Term Care Cases we take are on contingency, so there is no out of pocket expense for attorneys fees. If you, or a loved one, has a Long Term Care Claim denied, WE CAN HELP.