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LONG-TERM CARE CLAIMS AND APPEALS

New York Long-Term Care Lawyers

A doctor caring for a patient in a nursing home

Long-term care (LTC) insurance can cover or help offset the high costs of health care as we age, such as the costs of care in an assisted living facility, nursing home or home care. Including a long-term care policy in your estate plan can be a good way to protect your assets and your loved ones. But as with other types of insurance, carriers tend to deny the claim first and ask questions later. This can lead to an unexpected cash crunch - in addition to your family’s stress at an already difficult time. Further, every policy is different, with varying daily rates, elimination periods, a lifetime maximum and inflation riders which you will need to understand pretty quickly. 

It’s smart to seek the services of an experienced attorney like the long-term care claims and appeals attorneys at Cona Elder Law to prepare the initial claim for long-term care benefits. By doing so, we can wade through the policy for you, talk to the insurance company, and prepare the claim so as to avoid that typical first application denial. And if you do receive a denial of coverage and are facing an appeal, hiring the right attorneys like the knowledgeable elder law attorneys at Cona Elder Law is critical.

What Is Long-Term Care Insurance?

Long-term care policies are designed to cover or supplement the cost of home care, assisted living, nursing home care and other long term care needs. Long-term care comes in to play when you or a loved one requires assistance with activities of daily living, such as bathing, dressing, grooming, eating, using the bathroom, assistance with mobility or assistance due to cognitive decline, such as due to dementia or Alzheimer’s Disease.

The concept of long-term care insurance is much like any other insurance: the beneficiary files a claim to receive benefits under the policy when there is a qualifying event. However, the reality of getting a claim paid is often quite frustrating, as long-term care insurers frequently engage in delay tactics or deny otherwise valid claims for reasons ranging from self-serving interpretation of policy language to reliance upon biased doctors or nurses to justify the denial.

Whether through delay or outright denial, long-term care insurers often bank on a claimant’s frustration.  Unfortunately, many claimants do give up, allowing the long-term care insurance carrier to collect years and years of premiums without paying out for rightful and legitimate claims.  

Cona Elder Law attorneys use our decades of experience dealing with insurance companies and interpreting medical records to help guide you through this complex and daunting process. Many wrongful denials may be overturned without resort to litigation. A carefully and properly prepared claim or appeal by Cona Elder Law’s seasoned attorneys is one of the best ways to ensure you receive your benefits.


When to File a Long-Term Care Claim

It is best to file a claim for long-term care insurance at the first sign that there is a need for care, including a need with any of the activities of daily living (ADLs), that is, dressing, bathing, grooming, toileting, eating, or signs of cognitive decline where assistance, including safety monitoring, is needed. Since all long-term care policies have an elimination period or waiting period during which time you must pay for the costs of your care before benefits will begin, it is best to make a claim and start that elimination period as soon as possible. Depending on your policy, that elimination period could be 30, 60 or 100 days, which could cost you thousands to tens of thousands of dollars out of pocket.


Dealing with a Long-Term Care Insurance Claim Denial

If your long-term care claim has been denied, your insurance company has the obligation to provide the exact basis for the denial, which is typically disclosed in a denial letter. Once you know the basis for the denial, you may be able to provide additional information to support your claim.

Make sure you pay attention to the amount of time in which you must appeal the denial, which is listed in the policy. If you have exhausted all of your appeals and the insurance company continues to deny benefits, you have the right to file a lawsuit against the company for breach of the long-term insurance contract.





The Long-Term Care Claim Evaluation Process in new york

A long-term care claim is initially submitted to the insurance company via a written application documenting the medical history, current medical records, current care, and Activities of Daily Living needs. Thereafter, a telephone interview is often scheduled with the claimant or their representative (spouse, child, caregiver) to review the information provided. Next, the insurance company may send a representative to the home or assisted living where the claimant resides to interview the claimant and assess the need for assistance with the Activities of Daily Living. At this time, the case determination is made to approve or deny the need for services and qualifications under the long-term care plan.

Managing long-term care insurance claims is not easy. Knowing what benefits are available, how to maximize the amount of care to which your loved one may be entitled, and finding an informed care provider who can maximize that coverage will help your family choose the best plan of care.

Common Long-Term Care Insurance Denials

Long-term care claims are very often denied on the first application or submission. This may be because covering claims is very expensive. In New York, the cost of a nursing home is well over $100,000 per year and home care easily costs over $10,000 per month. 

The insurance company may make an initial denial of benefits due to:

  •  Failure to pay premiums
  • No prior hospitalization
  • Ineligibility based on Activities of Daily Living that Can be Performed
  • Failure to Meet Elimination Periods
  • Ineligible Care Providers
  • Excluded Medical Condition
  • Conflicting Medical Opinions

How an Elder Law Attorney Can Help with Long-Term Care Insurance Claims and Appeals

The experienced attorneys at Cona Elder Law will guide you every step of the way and will provide a clear interpretation of each step so you understand how the process works. Some of the most common issues we navigate for our clients include:

  • Strict filing deadlines
  • Waiting periods prior to being eligible for coverage
  • Specific appeals and claims processes
  • Limitations on the types of coverage for which you may be eligible

Requesting coverage or reimbursement for your claim can be frustrating, difficult and time consuming. Far too often, those who need long-term care insurance benefits do not have the wherewithal to fight with the insurance company, which is where we come in. The attorneys at  Cona Elder Law will fight for your rights and help you get the benefits you deserve.


Contact Cona Elder Law for LTC Insurance Claims and Appeals

When it comes to your long-term care insurance, you do not have to simply accept a denial of coverage. The New York Long-term care insurance attorneys at Cona Elder Law will fight for your rights and your benefits. We bring more than 20 years of experience helping residents throughout New York win long-term care insurance denials and appeals. Our unwavering commitment and in-depth knowledge of the long-term care insurance process allows us to prepare your claim properly and challenge any denial of benefits.

 Contact us today for experienced long-term care claims and appeals assistance.

New York Long-Term Claims and Appeals FAQs

If you are considering filing a claim for long-term care benefits, read on for a few more facts to help you decide when and how to submit your claim. 

What Triggers a Long-Term Care Claim?

A long-term care policy is typically triggered when you need assistance and care – at home, in a nursing home or in an assisted living facility. This is often because you need help with the Activities of Daily Living (ADL) – dressing, bathing, grooming, toileting, transferring, eating or because you need assistance due to cognitive impairment.
When you require help with 2 out of the 6 Activities of Daily Living or have cognitive decline such as due to dementia or Alzheimer’s Disease, you may submit a claim for long-term care benefits coverage.

Why Do Insurance Companies Deny Long-Term Care Claims?

It’s an expensive proposition to pay out on every long-term care claim. But your long-term care policy is a contract between your insurance company and you. They are contractually obligated to cover particular expenses as long as you meet the conditions and terms explained in the policy’s fine print. Unfortunately, this “fine print” is often very confusing and difficult to understand - which is why it’s important to work with an attorney to review why your claim was denied.

Do I Need a Lawyer for my Long-Term Care Claim?

Instead of facing the journey alone, it's prudent to seek the services of an experienced attorney to prepare the initial claim for long-term care benefits. By doing so, you can take steps to avoid a denial. However, if you do receive a denial of coverage and are facing an appeal, hiring the right attorney is critical. The long-term care claims and appeals attorneys at Cona Elder Law have over two decades of experience helping clients navigate their policies and claims to secure benefits to which they are entitled.

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