Part 1 of this series of posts addressing long-term care (“LTC”) policies provided background on the nature of these policies and why they are important aspects of estate planning.
This is Part 2 addressing some terms and conditions that are frequently the subject of disputes and claim denials. Denials can obviously be very upsetting and financially devastating for insureds and their families, especially the insured may already be experiencing physical and medical difficulties, and they and their families, having made premium payments for many years, expect claims to be covered.
Our lawyers have represented both insureds and insurers in LTC matters in both New York and Connecticut, so we understand the arguments and nuances involved in claims determinations. Here are some LTC terms that are commonly the subject of disputes:
- Medical Eligibility – A valid LTC claim requires proof, based upon the policy’s terms, that the insured is experiencing certain physical or mental impairment. For instance, policies often require a showing that the insured is “Chronically Ill.” This is often a defined term that means the insured, to qualify for coverage, must be unable to perform at least two (2) “Activities of Daily Living (“ADL”) (bathing, dressing, eating, etc.) without “Substantial Assistance.” Disputes often arise involving unclear or poorly documented claims.
- Credentials and Eligibility of Facility Provider – Many, older LTC policies were written to anticipate insureds’ need for “skilled nursing” facilities (nursing homes). LTC policies usually define the type of care that is eligible for coverage and may require that a facility or provider hold certain licenses and provide certain types of care. Disputes may concern whether at-home care or assisted living facilities fall within the scope of LTC coverage.
- Credentials and Eligibility of Other Provider – Similar issues as the above can arise concerning care provided by individuals. Policies often require that such individuals hold certain credentials such as nursing or therapy licenses or be working with a “Home Health Care Agency.” Often there are informal arrangements with individuals who lack such credentials. Such arrangements can be very helpful to insureds, but they can create coverage disputes.
Numerous issues can arise in the context of LTC policies. The above is meant to preview just some of them. As mentioned in Part 1, insureds and their families should consult with experienced counsel at the outset of the claim process, in order to help avoid a claim denial and delayed payment, and to ensure maximum coverage benefits.
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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