Long Term Care Disputes

It is no secret that finding safe, comfortable, affordable care for seniors is hard to do. You may think that you or your loved one is protected because of a forward-thinking decision to obtain long-term care insurance. Sadly, far too often that insurance fails to provide the security it was intended to give.

As the country’s population has aged, insurance companies have been overwhelmed by long-term care claims. With people living longer than they did when they purchased their policies decades earlier, these claims have created financial difficulties for the insurers. Most have stopped selling the policies or have dramatically rewritten them to offer fewer benefits. However, those insurers are still required to honor the policies they already sold. That requirement is putting many insurers in uncomfortable financial positions. UNUM Group, for example, which is based in Maine, was confronted by the Maine Department of Insurance recently for its unprecedented premium deficiency reserve, which totaled multiple billions of dollars. Where UNUM and other insurers are actively losing money on these policies, they are incentivized to find reasons to deny long-term care claims.

At Monahan Tucker Law, we understand. We know long-term care insurance and can help you navigate through these difficult situations. If your long-term care claim was denied, contact us to learn how we may be able to help.

Activities of Daily Living

One of the most common reasons for long-term care insurance denials is the insurer’s decision that the insured does not need sufficient assistance with the activities of daily living. Most long-term care policies state that in order to qualify for benefits, the insured must need significant assistance with at least two “activities of daily living.” These may be defined in the policy but are generally considered to be dressing, toileting, bathing, transferring (moving from a bed or chair) or mobility, eating, and continence. 

Policy language will often state that the insured must need “substantial assistance” with the activities at issue. “Substantial Assistance” is usually defined to mean stand-by or hands-on assistance to complete the activity. But the policies rarely account for real-world scenarios:

• Does the insured need hands-on or stand-by assistance every single time?
• Is their ability to care for themselves decreased in the evenings?
• What exactly is encompassed in “transferring”?
• If medication temporarily improves the insured’s functionality, does that improvement mean that they do not qualify for benefits?

The answer to these questions may seem obvious to the insured and the insured’s medical team, but the insurance company may decide that the insured does not need assistance badly enough and should re-apply for benefits when they have deteriorated further. The doctors who review the claim for the insurance company are paid by the insurer and are incentivized to find reasons to deny claims. Such decisions fly in the face of the intent of the insurance and should not be accepted by the insured.

Alleged Fraud

Another reason for long-term care insurance disputes is the insurance company’s subjective determination that the insured is not actually in need of assistance and is intentionally falsifying information. When an insured makes a claim for long-term care benefits, the insurance company will often send investigators to spy on the insured. As noted above, an insured may do better or worse throughout the day, based on the hour, based on medication, or simply based on having a good or bad day. If an insurance investigator staked outside of the insured’s home sees the insured conducting activities that they claimed they could not do without assistance, the insurer uses that snapshot of a single moment to argue that the insured is providing false information. These accusations are heartbreaking to the insured and their family, who feel as if they are being punished for trying to take advantage of brief times of increased ability in their declining years. 

In our practice, we have found that some investigators have broken laws in their surveillance, breaching privacy rights. Some have spliced together footage to make it appear that the insured was out at a time of day when the insured had stated he could not function. We have significant experience in fighting back against these unfounded allegations against insureds and forcing the insurers to admit their errors.

Insurance Bad Faith and Elder Financial Abuse Claims

Bad faith insurance claims stem from situations where insurance companies unreasonably deny valid claims. If an insurance company is found to have denied your claim in bad faith, it can be required to pay punitive damages to you. Unreasonable denial of insurance benefits is also a basis for finding that an insurer has committed elder financial abuse. This also can lead to an award of additional damages.

At Monahan Tucker Law, we know that entering into a dispute with a long-term care insurance company can be scary and overwhelming. If you are making a long-term care insurance claim, you are already managing the loss of freedoms that you or a loved one is used to having and navigating a new reality of needed care. Insurance companies know this and rely on the expectation that you will be too overwhelmed to push back on their denial. Our job is to stand up for you to the insurance company, so you can focus on yourself and your loved ones. Contact us today to schedule your initial consultation.