Across Texas, policyholders are experiencing a serious uptick in long-term care insurance denials.
If you or a loved one have long-term care insurance and are being treated unfairly by your insurance company, you have come to the right place. Whether your LTCI claim has been denied or you are ready to file initially for benefits, our long-term care claims attorneys are here to help you or your family get paid.
When we can no longer care for ourselves, a long-term care insurance policy is a powerful tool for paying the steep costs of nursing home care, assisted living, and home health services. But many who have purchased long-term care insurance (LTCI) are facing claim denials, terminations, and hiked premiums.
When an insurance company is unwilling to pay, the act of actually obtaining long-term care insurance benefits can be very hard to do on your own. Our whitepaper will help you understand what your initial LTCI claim needs to prove. You will aware of developments in the long-term care insurance industry, and what may be happening behind the closed doors of your insurance company.
If your claim has already been denied, you will learn how you can fight back with the right information and win the long-term care insurance benefits you deserve.
In Texas, long-term care can be very expensive, thousands of dollars per month. Cost depends on the kind of care, where it’s provided, and the type of care provider. Your LTCI policy may cover various long-term care service options, including:
- Home health care
- Care in a skilled nursing home
- Hospice care
- Respite care
- Assisted living facilities
- Adult daycare centers and other community facilities
But proving a claim for LTCI benefits is more complex than most realize.
Top Ten Long-Term Care Insurance Denial Tactics
Insurance companies are in business to make a profit. Some carriers resort to ethically questionable tactics that bring the highest return possible in premiums, then find ways to avoid paying your rightful benefits—leaving it to you to prove they are wrong.
- The policy definitions are vague or misleading, allowing the insurer to give interpretations of policy wording slanted in their favor;
- The insurer alleges your condition has improved and you are no longer eligible for continuing benefits, thereby terminating benefits;
- The insurer claims you do not meet the ADL requirement; this is often done using surveillance and social media to make it appear as though you can perform Activities of Daily Living that your claim says you cannot do;
- The insurer says you have submitted wrong or insufficient documentation. Most claim forms intentionally do not give enough room to explain why you qualify for coverage, so you leave out important information. Other insurers make the forms vague or so confusing that incorrect responses easily occur;
- The insurer overwhelms you with stacks of paperwork in the hopes that you’ll simply give up the fight against them;
- The insurer hikes premiums so high that your policy lapses — you’re unable to pay that amount because you’re on a fixed income. Although you’ve paid the premiums for years, your long-term care benefits are denied;
- The insurer argues that the long-term care facility is not properly licensed or does not meet your policy’s criteria;
- The insurance company fails to notify you of benefits that are rightfully due to you under your policy;
- The insurance company’s hired doctor, referred to as an independent medical examiner, may discredit your treating physician’s assessment of your condition.
- Your LTCI policy contains an older provision where prior hospitalization or prior nursing home residency is required for benefits to be awarded. Found in older policies, this is referred to as “the gatekeeper provision.”
How Our Long-Term Care Insurance Attorneys Can Help
Initial Claim Filing
Our law firm helps policyholders avoid mistakes and omissions that could lead to insurance denial. We can help you complete the application process swiftly and build your original claim to have the best possible chance of approval for the maximum benefits you deserve.
We organize essential medical records and objective medical testing in a way that facilitates the insurance company’s review. Our team assists in other meaningful ways, including the preparation of the claimant’s daily journal and family members’ statements chronicling the need for assistance with ADLs and how the claimant’s life has changed. We understand the facts that insurers will find to be credible and cannot justifiably refute.
Fighting Long-Term Care Insurance Denials and Terminations
With long-term care insurance, you must never simply accept the fact that your claim was denied. There are robust legal steps you can take to fight back and win your benefits. Most importantly, you should never have to face the insurance company alone.
Your insurer is legally obligated to specify the exact basis for denying your claim. The best thing you can do is contact an LTCI claims lawyer to see if you have a legal case against the insurance company. Your next steps will be determined by the terms of your policy. This will vary between insurance companies and the policies they offer. Under the policy, you may
- be allowed to provide the insurer with additional information to support the claim;
- be required to file an administrative appeal, known as appealing the denial, or
- file a lawsuit to go after benefits in court.
Whether appealing the denial or litigating the matter in court, you need attorneys on your side experienced in Texas insurance and contract laws, tort law, and consumer protection laws.
Appeal the Denial
Our lawyers are strong allies both in and out of the courtroom in the fight to appeal the wrongful denial of LTC insurance benefits.
In the administrative appeal, you will need to submit evidence that will support your claim, proving that your condition limits your ability to perform two or more activities of daily living, or as otherwise stated in the policy.
Marc Whitehead & Associates will take on the entire burden of the appeals process, to ensure all legal means are in place to hold your insurance company accountable. Our firm will help obtain the appropriate medical, cognitive and occupational documentation to establish your entitlement to benefits.
When litigation becomes necessary, Texas has many remedies available.
In the State of Texas, insurance and contract laws provide strong consumer protections and remedies against long-term care insurance denials, including:
- Breach of contract
- Unfair claim settlement practices
- Breach of duty of good faith and fair dealing
- Bad faith conduct
- Punitive damages
- Mental anguish or consequential damages
- Loss of credit
- Texas Deceptive Trade Practices-Consumer Protection Act damages
- Texas Insurance Code Violations
- Attorney fees
The carrier may have also breached its duty of good faith and fair dealing that is owed to you as the purchaser of the contract. In this case, the insurer acted in “bad faith” which may allow you to file suit to recover significant damages beyond the contract.
We Protect Your Long Term Care Insurance Benefits into the Future
The long-term care insurance provider will always explore ways to either deny a claim or terminate ongoing benefit payments. Insurers review existing claims monthly and evaluate whether a claimant remains eligible for benefits.
We offer ongoing benefit protection services, where your LTCI claim is continually updated and fortified to keep benefits in place.
Speak with a Texas Long-Term Care Insurance Denials Lawyer
Not all attorneys have dealt with these insurance companies again and again as we have. Many factors come into play in policy coverage. LTCI disputes tend to be fact-based and policy intensive.
Marc Whitehead & Associates will guide you through every step of the claims process. Our attorneys will work to overturn an unfair claim denial or restore a lapsed policy. We will deal with your insurance carrier on your behalf, so you can center getting the best possible care for yourself or your loved one.
Don’t let the insurance company force you to pay the massive costs of nursing home care or assisted living out of your own pockets. Winning the benefits you deserve calls for skilled legal representation, and we are here for you. Whether you were denied LTCI benefits, or you’re just now filing – we welcome your call. [Link to Contact Us]
Remember, timing may be critical to your case
- Call us directly: 713-228-8888 or Toll-Free 800-562-9830. Call any time, day or night.
- Contact us by e-mail. Fill out the brief, confidential form found on the right-hand side of any page on this site.
Based in Houston, we also have offices conveniently located in Cypress, The Woodlands, El Paso, Dallas, San Antonio, Temple, Beaumont and Pasadena.