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While some people take chances on relying on benefits provided through Medicare, Medicaid, or their regular health insurance, many people in Florida take out long-term care insurance policies to assist them with significant out-of-pocket expenses later in life. Long-term care insurance is intended to provide the necessary support for a person when he or she loses the ability to care for him or herself independently.
When a person with a long-term care insurance policy files a claim, it is not uncommon for an insurer to deny the claim based on an exclusion in the fine print of the contract, or as the result of missed payments.
Florida state law imposes very tight restrictions on insurers that allow victims to possibly obtain compensation for losses incurred as the result of unnecessary denials or improper handling of claims.
If your insurer is delaying or has denied your long-term care insurance claim, it is in your best interest to immediately retain legal counsel. Germain Law Group represents clients experiencing health insurance issues in St. Lucie County, Charlotte County, Hillsborough County, Manatee County, Pinellas County, and several other nearby areas.
Michael B. Germain is an experienced insurance attorney in Tampa who has received Martindale-Hubbell's AV Preeminent Rating, the highest possible rating in both legal ability and ethical standard. He can provide an honest and thorough evaluation of your case as soon as you call (813) 835-8888 to set up a free, confidential consultation.
Most long-term care insurance policies are comprehensive, meaning that they provide benefits for care in various settings, such as nursing homes, assisted living facilities, or even a person's own home. In order for a person to receive long-term care benefits, he or she must get a physician to state in writing that the person is unable to perform at least two of six Activities of Daily Living (ADLs).
ADLs are the six activities that most people are able to do every day without assistance. In most cases, the six ADLs include:
If a person is unable to perform at least two of the six ADLs, he or she must have some cognitive impairment. The Centers for Disease Control and Prevention (CDC) defines “cognitive impairment” as having “trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life." The CDC says Alzheimer’s disease is the most well-known form of cognitive impairment.
In addition to the ADLs or cognitive impairment requirement, most long-term care insurance policies also involve an "elimination period" in which the individual is expected to personally cover the costs of any services he or she receives. The elimination period can vary by policy, but most policies contain a provision stating that a person's ADLs or cognitive impairment must last for at least 90 days.
Insurers also will not provide any long-term care insurance benefits until the beneficiary presents an acceptable Plan of Care that is approved by the insurance company.
Long-term care insurance policies are frequently subject to a variety of red tape from insurance companies. Insurers find all sorts of reasons to deny claims, usually based on contractual provisions not being satisfied.
Some of the most common reasons that long-term care insurance claims are denied include, but are not limited to:
Florida Statute § 627.4133 establishes several requirements that apply when an insurance company cancels a policy for non-payment of premiums. When there are multiple reasonable interpretations of an insurance policy, the Supreme Court of Florida has held that the insurer must follow the interpretation which would be most favorable to the policyholder.
Statewide Medicaid Managed Care Long-Term Care Program — Florida deployed a Statewide Medicaid Managed Care Long-Term Care Program (SMMC LTC) system, also known as a nursing home diversion program, in 2013. Visit this website to learn more about eligibility, the Independent Consumer Support Program (ICSP), and LTC plan information. You can also find a link to a program overview and summary on the Agency for Health Care Administration (AHCA) website.
LongTermCare.gov — The Administration on Aging (AoA) is a United States Department of Health and Human Services federal agency that "promotes the well-being of older individuals by providing services and programs designed to help them live independently in their homes and communities." LongTermCare.gov is an AoA website that discusses what long-term insurance covers, receiving long-term insurance benefits, and buying long-term insurance. You can also learn more about long-term insurance costs and where to buy long-term insurance.
Is your insurance company refusing to pay your long-term care insurance benefits? Do not delay in contacting Germain Law Group.
Tampa insurance lawyer Michael B. Germain assists individuals in communities all over Sarasota County, Brevard County, Hillsborough County, Indian River County, Pasco County, and many other nearby areas.
Call (813) 835-8888 or complete an online contact form to have our attorney review your case and answer all of your legal questions during a free, confidential consultation.
This article was last updated on Friday, February 12, 2018.