Long Term Care

The most common Long Term Care Controversies are:

• What constitutes the type of impairments that should qualify the insured for benefits?
• What medical or functional proof should be required/sufficient?
• What remedies are available to a claimant when an insurer has unreasonably denied long term care benefits?

Long Term Care assistance are services provided by medical or non-medical individuals to assist a chronically ill or disabled insured.

Under Long Term Care insurance, benefits must be paid when a policyholder, as a result of a physical or psychological impairment,  is rendered unable to perform a specified number of the basic functions of every day living. These would include such activities as eating, dressing or bathing without assistance.  Because of the role played by such insurance coverage, Long Term Care Insurance benefits can dramatically affect an insured’s quality of life. The wrongful or unfair denial of benefits can result in severe hardship and depletion of savings and resources.

What constitutes functional impairments that should qualify the insured for benefits?

Benefits vary by policy and insurer. The policy terms and conditions will outline what is and is not included in the basic coverage. Additional benefits as addendums (riders) may also be available. Before purchasing a policy you should ask as many questions as necessary in order for you to completely understand the circumstances under which you may, or may not, receive benefits. As always, take careful notes on what you are told. Save these notes.  

What medical or functional proof should be required/sufficient?

Many LTC policies provide benefits when an insured as a result of a physical or psychological impairment becomes unable to perform two or more of the important functions necessary for independent living. An individual with a permanent hand, wrist, arm or shoulder injury, for example, may be unable to bathe or dress without assistance. The type of documentation required in order to obtain LTC benefits varies by policy and insurer, but in all cases, you should expect to be asked for supporting medical or other documentation.

When applying for benefits be careful to maintain a copy of all records including tests, and treatment records. You should also keep all correspondence with representatives of the insurance company. Take and keep notes whenever you speak to a claims representative or to your own medical or rehabilitation providers.

What remedies are available to a claimant when an insurer has unreasonably denied long term care benefits?

Understand your rights and responsibilities as a claimant. Unless your claim is ERISA Preempted (see www.InsuranceConsumers.Com. Also, see www.Bourhis-Mann.com  and read Insult to Injury: Insurance, Fraud and the Big Business of Bad Faith, by this author), certain principles under the laws of many states may be available to help protect you in the claims process. These rules can be very important in determining how a claim is handled. Protections often include the right to recover damages for all of the consequences flowing from an unfair or wrongful claim denial. Many states also provide for exemplary or punitive damages when an insurer has clearly acted “with malice, fraud or oppression.”

Although many carriers who provide Long Term Care insurance handle claims fairly and honestly, not all of them do. A front page New York Times article detailed the fact that many LTC insurers deny benefits knowing that their insureds are by definition older and in poor health and will therefore by unable to withstand the rigors of prolonged litigation.
(see: Aged, Frail and Denied Care by their Insurers,
N.Y. Times Mar 26, 2007).

For additional information, please contact Bourhis-Mann through our Questions form to request a case review. Be sure to include your state of residence when submitting your questions as laws vary by state.