It can be exceedingly distressing when your insurance company denies you treatment coverage, especially if you require long-term care. Luckily, there are options to help the victim ask the insurance provider to rethink their decision and explain why they should. This is known as an appeal. You should pursue the benefits entitled to you, as you have been paying the policy premiums to help you when you need long-term care and deserve them. Here are details of how you should a case of denied long-term care and how to seek help with a denied insurance claim.
Long-Term Care Insurance – What is it?
Long-term care insurance helps one pay for critical care if they become disabled. The insurance policy includes:
- Assisted Living
- Home health care
- Nursing home care
- Home modifications
- Adult daycare services
- Care coordination services
Long-term care policies are of two types, reimbursement and indemnity. Reimbursement policies pay a certain daily amount limit depending on your care costs. If your cost of care exceeds the daily amount limit, you will pay for the additional cost out of pocket.
Indemnity policies pay a specific daily amount benefit, irrespective of your actual cost of care. These policies are the same as cash benefit policies, which pay a specific amount daily.
Know the type of long-term care policy you have to understand the benefits you are entitled to.
Steps to Follow When Your Long-term Care is Denied
1. Know your appeal due date
Almost all long-term care denials allow the victim to file an appeal. Filing an appeal is essential as it is required when you want to file a claim in court. The ERISA policy gives a 180-day time frame to file an appeal after you receive a denial letter. If you are working with a lawyer, they will also need time to prepare for the case, so act fast.
2. Evaluate the reasons for denial
Subsequent to your denied claim, it’s good to evaluate your initial claim and establish why it was denied. Ensure you read and understand the denial letter and ask for your claim file from the insurance company. The reason could be a lack of medical evidence to sustain your claim, which may be easy to rectify depending on your situation.
Other possible reasons for denial include:
- Missed deadline
- Inadequate evidence to sustain the claim
- Conflicting medical documentation
- Exclusion of a pre-existing clause in the policy
- The claim does not qualify as a disability
3. Collect evidence
You may need to gather more evidence to prove your claim is necessary and legitimate. If you have filed a case with ERISA, new evidence is necessary. If the case ends up in court, you will only be allowed to submit evidence already in your claim file. Collect substantial medical records such as examinations, private records, medical bills, written doctor’s diagnoses, and proof of doctor appointments.
4. File the appeal
File your appeal only after gathering all pertinent evidence. Do not file an appeal without new evidence, and do not give up even if you feel overwhelmed by the process. Giving up is not an option, especially when you can engage a specialist to help with a denied insurance claim.
5. Hire a long-term care lawyer
Legal representation significantly increases your chances of succeeding in your appeal, especially if you hire a lawyer specializing in long-term care insurance and ERISA law. These lawyers know what to include in an appeal. Most significantly, your lawyer should be trustworthy. Find a lawyer who tells you the truth while being empathetic to your health situation. Having a suitable long-term care lawyer on your side will help you win a long-term care claim appeal.