If your parent’s claim has been denied, you can file an appeal with the company and in court if necessary. Help protect your parent’s rights before you file a claim and after you receive a denial. When you are ready, contact an attorney for help.
Insurance companies have a duty to handle all claims in good faith. In the case of long-term care insurance, however, policies are rarely profitable, and companies often deny legitimate claims. Often policies are older, written in the 1980s and 1990s before the evolution of long-term care and assisted living. The insurer may dispute what services are covered and bury the claim in red tape.
Before You File a Claim
An insurance policy is a contract, and its specific language is very important. A decades-old policy may distinguish between “Nursing Care” and “Home Health Care,” limiting the amount of coverage. The company may also cover only “medically necessary” services instead of support for “activities of daily living.” Especially if policy terms are somewhat outdated, a literal reading of policy coverage may be unclear. In South Dakota, if policy terms are ambiguous, ambiguities are supposed to be resolved to favor coverage.
To help avoid unfair denials, be sure a physician documents your parent’s medical needs. Your parent’s need for care at the level the doctor directs should be stated explicitly in medical records and doctor’s orders. Don’t make assumptions about what the insurer will cover. Have the doctor write it down to help prove your parent meets the policy’s eligibility requirements for benefits.
Ensure the facility or independent caregiver looking after your parent is eligible for coverage under the policy. Your insurance company may require a licensed caregiver employed by a regulated agency, even if your state has a lower standard for licensing of aides.
After a Claim Denial
A representative from the company likely visited the home or contacted your parent’s caregivers to process the initial claim. Get as much information as you can about what happened, including who the insurer spoke to and when. Keep a written record of your own contacts with the insurance company, past and present.
If you don’t already have a copy of the actual policy, get one as soon as your parent’s long-term care insurance claim is denied. Examine the reasons for denial in the letter from the insurance company. Gather evidence you need to counter the denial. If you suspect the basis of the denial, and can’t easily resolve the problem on your own, contact an attorney who practices in the area of insurance bad faith.
Attorney to Protect Your Loved One
It’s tough enough to take care of parents experiencing loss of health and independence. No one needs the added stress of an insurance dispute to make it worse. To ease the legal burden, contact a South Dakota insurance bad faith attorney today for assistance. Turbak Law can be reached online or at 605-886-8361.