Frequently Asked Questions for Long-Term Care Claims

If you are dealing with the challenges of a denied or delayed long-term care claim, you may have questions about your rights and options. Understanding the claims process can feel overwhelming, but you don’t have to navigate it alone.

For guidance and support, contact a long-term disability insurance attorney in San Diego from Dawson & Rosenthal, P.C. Our experienced attorneys can help you understand your policy, gather the necessary documentation, and advocate for the benefits you deserve. We are committed to fighting for your rights and ensuring you receive the compensation and care you are entitled to.

Reach out today for a consultation and let us help you secure the financial support you need during this challenging time.

What is long-term care?

Long-term care can range from a variety of services and support that help people – usually those suffering from a physical or cognitive disability – with daily living and safety. Often, long term care provides services and support for activities like bathing, dressing, eating, toileting, transferring, and continence, and may include supervision to keep you safe. Long-term care can be provided in assisted living or at home.

What is long-term care insurance?

Depending on the policy, long-term care insurance provides benefits for assisted living. Whether you need long-term care assistance in an assisted living facility or at home from a formal or informal caregiver, long-term care insurance may cover those costs.

Do I have long-term care insurance?

Carriers like The Prudential Insurance Company of America, CNA Insurance, and MetLife all sold long-term care insurance policies. However, these private companies, and many others, stopped selling long-term care insurance around or before 2012. If you bought a policy before then and continue to pay premiums, your long-term care insurance policy remains active. If you stop paying the premiums before the need arises, this means you likely do not have an active policy and will not be entitled to coverage.

Does my mom or dad have long-term care insurance?

This can sometimes be difficult to find out, if a policy is lost and your parent (or spouse, friend, etc.) does not remember. If your mom or dad has or had a financial planner, accountant, tax consultant, these are good people to contact and ask. If you think there is a long-term care insurance policy, and you know the insurance company, you can call them to find out if indeed there is one in place.

What are common diagnoses that require long-term care?

There are a range of medical diagnoses that could require long-term care. If a person needs assistance with certain activities of daily living, like bathing, dressing, eating, toileting, transferring, and continence, it could be based on any medical condition, including physical or cognitive diagnoses. Common cognitive diagnoses that can lead to a need for long-term care include Alzheimer’s and dementia.

Was my claim (or claim for my mom, dad, spouse, etc.) wrongfully denied?

If you have a long-term care insurance policy, you need long-term care, and your claim has been denied, we can help you determine whether the denial was potentially wrong.

What is a bad faith denial?

If your claim was denied without just cause, it might amount to a bad faith denial. Our firm can represent your best interests by taking that insurance company to court and fighting to uncover evidence of bad faith in the claim-handling process. If you have struggled with an unfairly denied long-term care claim, do not hesitate to contact our experienced lawyers online or by telephone at (928) 282-3111.

What Is a Chronically Ill Individual Certification, and why do I need one?

If you have a tax-qualified long-term care insurance policy, you may need to have a Chronically Ill Individual Certification to file a claim. This documentation is a defined requirement of the policy, which means a licensed health care practitioner must certify that you are chronically ill and have at least two Activities of Daily Living limitations for 90 days or you suffer from a severe cognitive impairment that requires ongoing, substantial supervision. Our healthcare provider must document that this type of care is likely to last at least 90 days.

Are housekeeping, transportation, and meal support available under long-term care insurance?

Most long term health insurance policies do not provide support for these types of services. Rather, they provide financial support for Activities of Daily Living. This includes help for activities such as bathing, toileting, continence management, and dressing. The policy will specifically outline what is covered and what is not.

Who can provide care to meet long-term care insurance requirements?

Some long-term health insurance policies will have a preferred care provider list. However, not all do. Most require that the person providing care have specific licensing through the state. The policy may have other requirements that must be met as well.

Can I help my parent with their long-term care claim?

If the person filing a claim is doing so on behalf of another person, a Power of Attorney must be in place, depending on the requirements of the insurance policy. If the person filing the claim is named on the policy, they do not need legal representation to file a claim or a Power of Attorney designation. However, even a spouse, adult child, or an agent working on behalf of the policyholder, a Power of Attorney may be required if any medical or financial information is being shared.

What happens during the claim review process for long-term care insurance?

Once a policyholder submits a claim for long term care coverage, a claims review process begins. This can take about six weeks to complete. This process typically involves a licensed health care professional, such as an RN, conducting an interview with the policyholder. All information and documentation to back up claims is then reviewed by the insurance provider. If there are any questions or concerns, the insurance company may request additional information. Once the insurer completes the review, a decision is made.

Can I file long-term care insurance claims if I enter hospice?

Long term care insurance coverage may have specific rules about this type of protection. Typically, eligibility will depend on the policy contract and the amount of need a person has for the Activities of Daily Living or supervision due to cognitive impairment. It is important to know that just having a diagnosis of terminal illness or chronic illness does not automatically qualify a person for long-term care claim coverage. Rather, they must demonstrate a need for professional, licensed medical care and support as defined by the policy to obtain coverage. Hospice does not automatically qualify a person for coverage, even with conditions such as Alzheimer’s disease or cancer.