Nationwide and Florida Long Term Care Attorneys

Your Greatest Fear?

Florida is home to over 4 million people over the age of 60 and many have come to Florida, either permanently, or as winter residents to enjoy our great weather. The miracles of science have prolonged our lives but, as we age, we naturally have health issues that can limit our ability to do basic life activities. Is that you?

Because you did not want to be a burden on your family and wanted to be as independent as possible, you may have bought a long-term care insurance policy to provide you peace of mind.

There is no uniform long-term care (LTC) policy and many LTC insurance companies have different versions of their policies. Sick, aged, and incapacitated policy holders are often victimized by LTC carriers who tell them the long-term care benefits they need are covered by their policy or that benefits are limited, when in fact that is not often the case. Despite paying large expensive premiums for years and years, LTC insurance carriers are counting on you or your family to walk away.

The LTC carrier will often cite fine print in the policy or interpret the policy in a way that results in a denial of a claim.

Walking away is a mistake that you and your family can’t afford. Don’t give up and let the LTC have an easy win while you and your family face financial ruin because the LTC failed to keep the promise it made to you when you bought the policy.

Did You or a Relative Buy a Long-Term Care Policy and Now Need to Use It?

Have you or a loved one become unable to perform Activities of Daily Living and need long term care because of:

• Alzheimer’s Disease and dementia
• Multiple Sclerosis (MS)
• Parkinson’s Disease
• Stroke
• Fractured bones caused by a fall
• Head injury
• Recovery from an illness, injury, or surgery
• Rehabilitation after hospitalization

What Most Policies Cover

1. 24-hour care
2. Nursing home care
3. Assisted living facility care
4. Home health aides
5. Medical equipment

Your long-term care (LTC) insurance may pay part of the daily cost of long-term nursing home or home healthcare. This care is often referred to as “custodial care” and consists of helping you perform the activities of daily living (ADLs) like using the bathroom, walking, eating, dressing, and bathing. In order to qualify for benefits, many LTC policies require that the insured person be unable to perform two or more of the activities of daily living.

Many long-term care policies are written in such a way as to limit the care you thought you were purchasing or make it difficult to get the benefits and money you were promised in your policy. By offering illusory coverage these companies, like Continental Casualty, Liberty Mutual, Unum and Mutula of Omaha, can turn your greatest fear into reality.

These big insurance companies are in the business of making money. Lots of money! They collect your premiums and invest the premium by buying real estate, stocks, and bonds. The long-term health care insurance company is more worried about their bottom line and their shareholders than what they promised you when they sold you your policy.

LTC policies have exclusions and limitations and can destroy your claim before you even file a claim or appeal a wrongful denial or termination of benefits.

Understanding Your Long-Term Care Policy and How to Avoid Making Crucial Mistakes That Can Destroy Your Claim for Long Term Care

Unfortunately, you can be left financially destitute if your long-term care insurance claim is denied or payment is delayed, and you have to pay the crushing cost of long term care out of your own pocket.

What benefits are paid and when they are paid depends on the language in your policy. What your long-term care policy covers is determined by the contents of your insurance policy. That policy is a written contract between you and the insurance company.

You need to understand what your policy means before you make a critical mistake that could destroy your claim for long term care. Not only can the fine print in your policy derail your claim, many LTC carriers interpret the terms of the policy in their favor.
Why?

The more premiums they collect and the more claims they deny, the greater their profit.

But we know firsthand, based on our own parents’ experience, what it is like to fight a big insurance company and win the benefits they were promised. As a result, we know how to level the playing field and help clients through the claims process from beginning to end, protect our client’s rights and fight for what is rightfully theirs. We know you are not asking for a handout but want the benefits you paid for with your hard-earned dollars.
We want to empower you and assist you in getting your long-term care benefits quickly.

That’s why we wrote a book on LTC claims.

It is crucial that you understand your policy, the application process, the mistakes you can make that will destroy your claim and how you can make sure that your rights are protected against the bad faith insurance practices of many long-term health care carriers.

Don’t be surprised if the LTC carrier cherry picks your medical records or the forms your doctor has filled out in support of your claim. Sometimes, the treating doctor just doesn’t get it right. Regardless, an experienced LTC lawyer like those at Cavey Law, can help your doctor explain medically why you need assistance with the covered Activities of Daily Living and overcome the bogus reasons for the carrier’s denial or termination of benefits.

What Does Your Long-Term Care Insurance Cover?

It depends on what you bought! Your coverage will vary based on the terms of the policy. You can purchase:

1. A “facility only” policy that provides only nursing care or.
2. A “comprehensive “policy that provides a mixture of care options, such as home care and care provided by a family member or friend in your home. The policy may also provide services or equipment that helps you stay in your home. This may range from in-home equipment like an electronic monitoring system, home modifications like grab bars or ramps, transportation to your medical appointments and even training a friend or relative to provide you with safe and appropriate personal care.

You can also add coverage options, called riders, to provide you with additional coverage under your policy. These riders can include:

1. A “non-forfeiture benefit” that provides that some benefits will be paid even if premium payments are not made, and your policy is cancelled because of non-payment of premiums.
2. “Inflation protection” protects you against the inevitable rising cost of care by increasing the amount of your insurance coverage.

It is important that you understand what the long-term care agent sold you and what coverage you really have. Don’t make the mistake of thinking that just because you have a policy the care you need will be provided.

Before you file an application for benefits, Cavey Law can review your policy, explain what coverage you have, and help submit a winning application for benefits. We want you to have a path forward that is best for you and your family.

What Triggers My Benefits Start and When Will My Benefit Start?

Triggers

The answers are found in your policy. When your benefits start will depend on the triggers that are found in your policy. The way benefits are triggered vary from policy to policy and what benefits you are entitled to also have triggers that vary from policy to policy. A starting point is the definition section of your policy.

Although many insurance policies vary, the most common benefit triggers for long term care insurance are:

1. Medical Necessity
2. Loss of Functional Capacity and
3. Cognitive Impairment

Medical Necessity may be defined as

“. . . care due to Sickness or Injury. The care prescribed must be consistent with accepted medical standards for treating the diagnosed condition and could not have been omitted without adversely affecting your condition.”

Medical necessity is a broad trigger but one of the most ignored by long term care insurance companies.

Loss of Functional Capacity

Most policies use an inability to perform certain “Activities of Daily Living (ADLs) as a trigger to determine if you are eligible for long term care benefits. The policy will pay benefits when you need help with two or more of the six Activities of Daily Living, or you have a Cognitive Impairment.

What are the Activities of Daily Living? These include:

1. Bathing
2. Dressing
3. Walking
4. Moving from bed to chair
5. Toileting and continence; and
6. Eating

Before paying benefits, the long-term care insurance company will require certification by a physician or licensed practitioner that you cannot perform at least two out of six of the activities of daily living because of physical or cognitive impairments.

Your policy will define Activities of Daily Living and tell you the number of Activities of Daily Living you must be unable to perform to qualify for benefits. An example of a definition of Activities of Daily Living (ADLs) is:

You need active personal assistance to perform at least two of the six defined Activities of Daily Living.

• Bathing: Washing you by sponge bath; or in either a tub or shower, including the process of getting into and/or out of the tub or shower.
• Continence: Ability to maintain control of bowel and bladder functions; or when unable to maintain control of bowel or bladder functions, the ability to perform associated personal hygiene (including caring for catheter or colostomy bag).
• Dressing: Putting on and taking off all items of clothing and any necessary braces, fasteners, or artificial limbs. This included buttoning buttons and tying shoes.
• Eating: Ability to, without the aid of another person, maintain an adequate food and fluid intakes consistent with dietary needs.
• Toileting: Getting to and from the toilet, getting on and off the toilet and performing associated personal hygiene.
• Transferring: Moving into or out of a bed, chair, or wheelchair. Transferring does not include the task of getting in or out of the tub or shower.

Sometimes the long-term health care companies will require you to have hands on assistance to perform the Activities of Daily Living before you qualify for benefits, while other policies will provide benefits if you only need stand by assistance. The devil is in the details.

Obviously, it is easier to claim benefits if your policy has more than five Activities of Daily Living and if your policy includes bathing as one of the Activities of Daily Living.

Cognitive Impairment

The long-term health care policy may have, as a trigger for benefits, the need for supervision and direction because of a Cognitive Impairment.

Cognitive Impairment caused by conditions like Alzheimer’s, early onset dementia or brain injuries are common conditions that trigger benefits. While you may not need physical assistance, you may need supervision to make sure that you and others are safe because you can’t remember to turn the stove off or roam the area.

When Will My Benefit Start?

Once the trigger is set off, the next question is “When will my benefits start?” Most policies have what is called an “elimination period” which is the amount of time that has to pass from the time the trigger is set off and until your benefits must be paid by the long-term health care carrier. The elimination period can range from your benefits starting immediately or can be as long as 100 days. You are not entitled to any benefits until that elimination period is satisfied, regardless of how desperately you may need care.

After the trigger for your benefits is set off and you have waited out the elimination period, the amount of your benefits will depend on what coverage you purchased! Most long-term care policies provide a daily or monthly benefit.

The daily or monthly benefit is what your long-term care insurance company will pay each day or month you qualify for benefits. Some policies will pay a pre-set amount of cash whether or not you actually get care while others reimburse you for the costs you actually paid for the long-term care services.

What happens if the cost of your long-term care is more than the maximum daily or monthly benefits you bought? The difference is your responsibility!

How much the policy pays and how long the policy pays will depend on what coverage you bought! You can purchase a policy that only pays for 2 to even 6 years of benefits or more expensive policies that pay benefits for your lifetime.

You can see why it is important to understand your LTC policy.

The Application for Benefits and The Mistakes You Want to Avoid

Navigating the long-term care claim process can be confusing, complicated, and frustrating. You can inadvertently make mistakes throughout the whole claims process and even after you start getting your long-term care benefits.

The claims process starts with filing an Application for Benefits. The mistakes you can easily make in the Application for Benefits can result in delay or even the denial of the payment of your benefits which can be emotionally exhausting and financially devastating.

You need help with the Application for Benefits, and you need it quickly! If you are dealing with illness or serious injury, your financial and medical independence is at risk when you file a long-term care insurance claim.

But before you file your Application for Benefits, you must understand both your rights and your obligations under your policy and under the law. You must understand what benefits your policy provides, how to make sure you get the care you deserve and are entitled to under your policy and the procedure you must follow to get your benefits. If you don’t have this basic understanding, you are setting yourself up so the carrier can delay or, worse yet, deny your benefits. Why would you want to do that to yourself?

Filing an Application for Long Term Care Benefits Under Your Policy? Not So Fast!

Before you file an Application for Benefits, you MUST get a copy of your policy. That is your starting point. Your policy is a legal contract that was written by insurance company attorneys for the benefit of insurance companies and not for your benefit. It is crucial that you read your policy before you make ANY decisions about your care and that you understand the policy terms and requirements. We like to think of the long-term care policy as a road map. If you don’t have a map, you just won’t get where you want to go and get there quickly. The policy gives you directions that tell you what you must do so you can quickly get your benefits.

1. You must give your insurance company notice of your claim.
2. You must give the insurance company timely notice of your claim within the required time.
3. You must provide adequate proof of your entitlement.

Sounds easy, but it isn’t. If you don’t do these things right, your claim will be denied. It is as simple as that and that is why filing a claim for long-term care benefits has to be done right. The application should be done right the first time so there is no delay or denial of your benefits.

The Application for Long Term Care Benefits

The Application for Benefits is one of the most important documents you will complete when you make a claim for your long-term care benefits. What you say on the application, what you don’t say on the application and even how you complete the application can make or break your claim. Your mistakes can haunt and even doom your claim from the very beginning.

The Application for Benefits has been written by your insurance company and, while it looks like a simple application, it is filled with minefields that can destroy your claim. The application often purposely doesn’t ask the right questions or give you an opportunity to explain your situation. In fact, the application is designed to elicit information from you to deny the claim. Yes, that is right! Deny your claim! Carriers often purposely misconstrue or take out of context the information you provide for the purpose of denying or delaying your claim. Long term care insurance companies are in the business of collecting and investing your premium dollar. They are NOT in the business of paying legitimate claims.

You need an experienced long term care attorney to review with you the insurance policy, determine what benefits you are in fact entitled to under your policy and help you complete and file a winning application for your long-term care benefits. Only an experienced long term care attorney can identify problems with your claim and application before your claim is unfairly delayed or denied.

The Interview/Statement Process

Many long-term care policy holders think that getting their benefits started is as simple as having their treating doctor write a letter. We wish it was just that simple, but it isn’t!

The next step in the carrier’s claim process is for your statement to be taken either in person or by phone. Long term care insurance companies spend a lot of money, time, and energy to train their field investigators and claims adjusters on how to handle a claim. Did you notice the titles we just used?

Now, we know you have nothing to hide and desperately need your long-term health care, but the term “Investigator” should give you pause. Long term carriers investigate these claims. That means they may do a background check on you by checking social media sites like Face Book, Linked-In, J-Date and even gaming sites. It is all fair game! Pictures you or your family post about family activities like vacations, birthday parties or what everyone is doing this weekend can come back and haunt you when the investigator takes your statement.

Long term care companies also use video surveillance to see what you are doing and whether what you put on your application is really consistent with what the camera captures.
The other term we used was “adjuster.” The title is not “claims processor” but “adjuster.” We think that word says it all. The adjuster is trained to treat your claim like a paper file. The adjuster is trained to think that everyone who files an Application for Benefits is a fraud and not to be trusted. The adjuster’s job is to find a reason to delay the payment of your benefits hoping you will become frustrated or to deny the payment of your benefits hoping you will go away and not fight.

Whether your interview/statement is taken by an investigator or adjuster, both have been trained on how to ask questions that will result in answers from you that later can be misconstrued and even taken out of context. They have no compassion or even empathy for you and your desperate need for your benefits. Their goal is to defeat your claim.

If you aren’t prepared, your statement can be the ammunition the long-term care insurance company needs to deny or delay the payment of your claim.

We have written a consumer guide on how to prepare for a statement that we give to all of our clients, so they know what to expect and how to prepare for the carrier’s tricky questions. After you have read our book, we prepare you for what questions you will most likely be asked and how to properly answer those questions. All “in person” interviews should be video recorded, and any phone statements should be audio recorded. There should be NO questions about what was said during the statement.

You need an attorney familiar with your case to be with you during that statement to protect your rights. We can make sure the investigator or adjuster doesn’t ask you ambiguous, tricky or even unfair questions.

We insist that we are given a transcript of the statement so we can make sure the transcript is correct and correct any mistakes that you might have inadvertently made.

Common Delay Tactics Used by Long Term Health Care Companies

There are 4 common delay and denial tactics utilized by long term health carriers every day, day in and day out:

1. Slow Walking
2. Cancellation of your Policy due to non-payment of your premiums.
3. Misconstruing your policy and/or the facts of your claim.
4. Post claims underwriting.

Your long-term care carrier is in the business of collecting premiums – your hard-earned money that you saved to protect your financial and personal independence. They are NOT in the business of paying benefits – don’t let that surprise you. So, now that you understand the carrier’s financial motivation, let’s take a closer look at the common delay and denial tactics you will face. Not maybe face-will face.

Slow Walking

Long term care insurance companies delay paying your benefits by continually asking for additional information, duplicative information and information that is, quite frankly, unnecessary. Why? Simple!

This is a game of attrition. They want to wear you out, hoping you will give up or just forget to send in the paperwork! Worse yet, the carriers hope that you are too sick or too disabled to fight or that you will die before your benefits are paid. That is cruel and heartless. They are hoping that policy holders, like you, won’t have friends or family members who can find a long-term care attorney who can fight for them.

And the insurance company will tell you that without this “additional information,” they can’t approve your claim. Don’t believe them! Don’t give up!

Cancellation of Your Policy Due to Non-Payment of Premiums

Did you know that under your policy there is a grace period for you to bring your premium payments current? But guess what? Many long-term care insurance companies ignore their own policy provisions and even state law in their rush to cancel your policy.

What happens if you have Alzheimer’s or Dementia that impacts your ability to remember simple things like paying your bills and your insurance premiums?
You are protected under Florida law from these wrongful terminations!
What happens if you can’t keep up with your premium payments because of financial problems?

Your policy may require that a third party, like a friend or family member, be given notice of your non-payment of premiums before the insurance company can lawfully cancel your policy. That policy provision is called a “third party designee” and is designed to protect you! But guess what? Many long-term care insurance companies ignore their own policy provisions and even state law in their rush to cancel your policy. Do you see a recurring theme?

You can, under the right circumstances, fight to have your policy reinstated and benefits paid, even when the deadlines have passed, under state law or under the terms of your policy.

Misconstruing Your Policy and/or the Facts of Your Claim

This is a carrier favorite, and it takes two different forms. The first form is misconstruing the terms of your policy- the policy that the carrier wrote. Here are common examples of “misconstruing” the terms of your policy:

1. The long-term care services were NOT provided by a properly qualified professional or service provider as defined by your policy.
2. The long-term care services provided for you are available under Medicare or another governmental program.
3. The long-term care services you received are NOT covered under your policy.
4. Your medical condition is NOT covered because it is the result of mental illness, attempted suicide or intentionally inflicted injury, alcoholism or drug addiction, war or acts of war.
5. You have a pre-existing medical condition and are barred from getting benefits.

The second way your carrier will misconstrue the facts of your claim can include:

1. You were NOT hospitalized prior to needing long term care.
2. You do NOT have an acute medical condition.
3. You are NOT unable to perform your “Activities of Daily Living.”
4. The care or services are NOT related or are NOT necessary for you to carry out your activities of daily living or are unrelated to your needs because of a cognitive impairment.
5. You do NOT need the level of care you were provided.
6. The long-term care insurance company doctor, who has never examined you, says that you do NOT need the care your treating doctor says you need.
7. You have NOT, despite repeated requests, provided sufficient verification of your need for long-term care.

Post Claim Underwriting

Long term health care providers try to avoid paying valid claims by taking a “second look” at how and why your policy was issued. The insurance company “reasons” that since you now need the benefits, the carrier must have miscalculated how much of a risk you really were when they issued the policy to you.

The insurance company does an “after the fact” evaluation to “fire” you and deny coverage. The long-term health care insurance company had all the information they needed because you filled out an application that disclosed your age, your health history and other important information. The carrier then had their underwriting department determine if they were going to offer to insure you, for what conditions, the nature of the care they would offer and the premium. If you have pre-existing medical conditions, the insurance company has an obligation to investigate those facts before they offer you insurance.

Take a look at your application. If your insurance company did not ask for a physical examination, asked only if you were in “good health”, only asked for yes or no answered to questions about your health or didn’t ask any questions about your health, it is likely the insurance company will do post claims underwriting as part of its normal “evaluation” of your claim.

When you file a claim, part of the post claims underwriting game is for the long-term health care company to obtain your medical records, review the records and look for a reason to deny benefits. The insurance company will find some omission or inconsistency in your medical records as compared to what was or was not put on your claims application. Guess what? The carrier will deny coverage on the basis of misrepresentation, concealment or fraud in your application, and you will get a letter that says:

1. Your policy is rescinded.
2. Your premiums are refunded; and
3. You have no coverage for your claimed loss.

While this is not an exhaustive list, the list is exhausting. Are you getting a real sense of the games long term care providers play to rob you and your family of peace of mind? So how can you protect yourself?

Your Long-Term Care Claim and Why We Hold LTC to the Promises They Made to You

A long-term care attorney will anticipate all the unfair delay and deny tactics used by your insurance company and guide you through your policy, benefits, and claims process. You need an experienced attorney BEFORE you apply.

A well-prepared application can prevent your claim from being denied. We work with you and your family so you understand what long-term care benefits your policy provides and identify the proper type of providers and facilities covered by your policy so you can make the best decisions for your personal circumstances.

We work with attendant care professionals, functional capacity evaluators and life care planners to document the level and type of long-term care you need.

We also work with your doctors to properly document your care. It is a team effort.

Legal Help When Your Claim is Delayed or Denied

We challenge the insurance company, gather the right information, and submit that information to the long-term carrier so they are forced to make a decision and provide your benefits.

And, we are not shy, in the right case, to negotiate with your insurance company to get your benefits NOW. But there are times when the long-term care insurance company just acts wrongfully. Then it is time to file a lawsuit. Sometimes you must sue your insurance company to get the benefits you paid for, and you rightfully deserve.

The law that governs how a lawsuit is filed will depend on whether you have a private policy which will be governed by state law, or you may have purchased your policy through your employer which will be governed by a federal law called ERISA (Employment Retirement Income Security Act).

A state law claim is very different from a Federal claim. That is just one of the reasons it is important that you get a copy of your policy so you can understand your rights, your obligations and whether you can bring a lawsuit in the state or Federal Court.

You have paid a precious penny for a policy to protect your family, your income, and your future. The carrier has put that future at stake, and this is the time to do what is right for you and your family and fight for your benefits.

We pursue your claim and protect your rights under state and Federal ERISA law. Our goal is to get you’re the full benefits you are entitled to under your policy. We handle long term care cases throughout Florida, the Southeast and nationwide.

If your claim is denied you should immediately call us. We will explain your policy, your options, your rights and what it will take to make the LTC keep their promises.

We know how LTC work and the games they play at the very time you need help. They know that you might be too frail, ill, or cognitively impaired to fight. Many times, it is your spouse, children or other relatives that step in and help but they just don’t where to turn.

Legal Help When Your Claim is Delayed or Denied

We can help:

• Explain your policy and your options,
• File a long-term care insurance claim,
• Dispute a wrongful denial or termination of benefits,
• Handle a lapsed policy defense,
• Appeal a denied claim,
• Negotiate a resolution of your claim,
• Negotiate a policy buyout,
• File a lawsuit and pursue, as allowed by state law, a bad faith claim.

What You Should DO if Your Long-Term Care Claim is Slow Walked, Denied or Terminated

If your claim is being slow walked, denied, or terminated it is time to get help from Cavey Law. To get started, call our office to schedule a 30-minute consultation. If you are applying for benefits, we will need a copy of the long-term care policy that you can get from the agent.

Why Do We Need the Policy?

There is NOT just one uniform long term care policy! Every long-term insurance company has their own policy and, in fact, many versions of a long-term care policy. That is why it is crucial that we see the ACTUAL policy so we can read it from cover to cover. We don’t charge for looking at the policy and giving you our thoughts about what your policy does and does not cover what you have to do to get your benefits and what hidden dangers are in your policy.

Why Do We Need a Copy of The Denial or Termination Letter?

If your claim has been denied or terminated the carrier has to send you a letter explaining why. As we explained, carriers have all sorts of reasons to deny or terminate benefits and the carrier’s letter will help pull the curtain back so we can get to the policy terms, medical evidence, and basis of the denial. Remember the basis of the denial or termination is often wrong but it will give us a road map to challenge the denial or termination.

If we think we can help you, we can explain what needs to be done and how long it can take to get benefits. We only handle cases on a contingent fee basis which means that we are only paid when you get paid.

Don’t let the carrier put their profits first and not the promises they made to you and your family.