This article is part of a series that will address basic aspects of long-term care (“LTC”) insurance claims and legal issues. Part 1 (below) addresses basic issues and provides background. Part 2 will address specific terms and conditions that commonly result in disputes. Part 3 addresses insurer bad faith.
Long-term care insurance policies are a common aspect of estate planning. Very generally, a LTC policy can provide coverage for costs associated with nursing homes, rehab facilities, and at-home care where an insured is unable to perform two or more “Activities of Daily Living” (“ADLs”). Other policies trigged coverage based on terms such as “medical necessity.”
As most readers of this article already know, LTC situations can arise for myriad reasons, but often involves a physical disability, a chronic health condition, or cognitive impairment, which issues obviously have a significant impact on the elderly.
Given the exceptional and rising costs of LTC, LTC policies can help insureds and their families avoid crippling and devastating financial problems. For many, ongoing situations mean that a lifetime of savings are at risk of being wasted away, unless a LTC policy is available to and provides coverage.
LTC policies, like any other insurance policies, are contracts, and the parties’ respective obligations are governed by the policy language. Each policy must be construed on individual basis, based on its actual terms and conditions as applied to a submitted claim.
Claim denials and insurance coverage disputes between insurance companies and insureds are common, and it important for insureds to remember that insurance companies are always being advised by experience insurance counsel. Many law firms seeking to represent insureds hyperbolically claim that all insurers act in bad faith. We have represented both insurers and insureds and we do not take that view, in fact, most insurers act in good faith. This said, there are exceptions, and frequently there is room for disagreement about an insurer’s obligations under the insurance contract. Where an insurer breaches its obligations by wrongfully denying a claim, it should be held accountable.
Based on our firm’s many years of insurance coverage and LTC insurance coverage experience in New York and Connecticut, we believe that insured with a potential LTC claim should consider retaining counsel before a claim is submitted. Doing so helps insureds assess available coverage, gather and submit evidence supporting the claim, comply with the insurer’s claim submission processes, and negotiate with the insurance company as needed. All of these will maximize recovery, and these issues are best considered prospectively and at the outset of the claims process, rather than after a claim denial.
This content is provided as background and does not constitute legal advice. The attorneys at our firm have many years of experience with LTC issues. For more information or to schedule a free consultation, contact us at info@lalorattorneys.com / 646.818.9870.
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