Long-term care insurance provides peace of mind against costly long-term care bills; however, many insurers will deny claims due to ineligible criteria or poor plans of care drafted.
Ensuring the claim filing process runs smoothly takes skill and precision; an attorney or claim filing service that specializes in this policy area may be invaluable assistance.
1. Contact the Insurer
First and foremost, Kligmann recommends speaking directly with your insurer to determine what can be done. There may even be an on-call manager available who may assist. If this approach doesn’t work out for you, state insurance regulators or even an ombudsman may help to facilitate resolution of issues that arise.
Understanding the requirements of your policy, particularly its triggers that must be fulfilled before coverage begins is vitally important. While these are typically defined in your policy document and updated periodically as needed. A facility’s status as an eligible provider may also change over time and insurance providers are obliged to notify you whenever any such change may affect your benefits.
Obtaining assistance from an impartial third-party such as an Ombudsman may be necessary if your insurance company cannot resolve an issue on their own. The National Association of Insurance Commissioners provides an ombudsman database where you can search for one near you.
2. File a Claim
Many LTCI policyholders can become disgruntled by delays, phone tag, and long hours on hold while their insurance claim is being processed – especially if an insurer denies one for various reasons. To minimize these problems and ensure smooth proceedings during claims processing, it’s vital that individuals understand how the claims process works as well as preparing ahead for it. To do this successfully.
Step one of filing a claim is informing the insurer of your need. Typically, this involves submitting a proof-of-loss form provided by the insurance company and providing relevant medical documentation – such as a Plan of Care listing the type and frequency of care needed, with endorsement by a physician or nurse practitioner endorsed endorsed Plan of Care document endorsed. Failure to properly provide this information could result in its denial.
Insurance claims may also be denied when their beneficiaries do not fulfill a set of criteria laid out in the policy. Therefore, it’s essential to research any facility thoroughly to ensure it satisfies insurer requirements before signing contracts or seeking treatment from specialists if applicable. Furthermore, prioritising physician pre-approval is also key – in case this requirement applies.
Last but not least, insurers typically request an authorization to release information form from both their insureds and legal representatives in order to comply with HIPAA and obtain medical documentation necessary for processing a claim.
If a claim is denied by an insurance company, they must send out written notification within certain time frames (depending on the type of claim) informing both parties about their right to file an appeal and why the claim has been denied. In their notification they should also detail how it occurred.
Keep in mind that insurance companies are in business to sell insurance and will make every attempt possible to avoid paying claims. Therefore, it is crucial that you review carefully the terms of your LTCI policy as well as work with an attorney or filing service that specializes in this field.
3. Appeal the Denial
Insurance companies should provide instructions on how to file an appeal in their denial letter; if not, be sure to request it. Furthermore, keep track of all communications with them from that initial phone call or fax transmission forward.
An appeal is a way of asking an insurer to reconsider and review their original decision on your claim. Sometimes the original decision was incorrect; sometimes it may have been determined on lack of sufficient documentation supporting your case; thus making reading denial letters with caution important.
Be polite and respectful while remaining brief when writing an appeal letter to an insurance provider. Briefly explain your reasons for believing that your claim should be covered and include any supporting documentation that might exist. Arrange it so the insurer understands all your points easily.
If you need an answer quickly, consider asking the insurance company to expedite your appeal – this process usually allows them to give a decision within 72 hours after receiving it.
Once your insurer has reviewed and denied your internal appeal, you have the right to request an external review by an impartial third party. To request this option, refer to the denial letter sent from your insurer or contact their customer service number listed on your health insurance card for details about how and when to do it.
As this process can be complex, legal help may be required to assert your rights and defend them effectively. Do not attempt to contest your long-term care insurance denial on your own; hire an attorney familiar with Texas insurance and contract laws, tort law, consumer protection, and appeal proceedings to appeal any wrongful denial of benefits as well as litigation if necessary. Reach out to our firm now so we can discuss our available solutions – we understand the frustration you feel when insurance companies refuse to honor their agreements and work tirelessly towards finding an expedient resolution quickly and fairly for both parties involved. Contact our firm now so we can discuss all available solutions! We look forward to working hard towards finding an amicable resolution!
4. Hire an Attorney
Have an attorney on your side can be key in getting the respect and results from your insurer. They can negotiate on your behalf or file suit on your behalf if necessary if they fail to honor their contract obligations. Attorneys can also track communications between yourself and insurer and compile any relevant evidence necessary for your case. Many offer free consultations while working on contingency, meaning their fee will come out of any compensation received by you.
Experienced attorneys can assist in helping you understand what your policy covers, as well as whether any changes have taken place since purchasing it that could impact its coverage. Furthermore, they can assist with creating and filing a long-term care plan required by many insurers before beginning payment for long-term care services; such plans typically outline your needs along with who should provide that care support and how.
If your insurer is taking too long or refusing to pay, an attorney can assist with resolving the dispute through formal appeals process or even court. In certain instances, they may have even acted in bad faith which allows for additional damages beyond what was stipulated in your contract.