Uscher, Quiat, Uscher & Russo, P.C. is a leading long-term care (LTC) law firm in New York and New Jersey. We offer more than 40 years of experience in litigation and insurance law.
Planning for the future becomes increasingly important as we age, and long-term care insurance often plays a crucial role in that preparation. It’s designed to shield individuals and families from the substantial costs associated with extended medical and personal care services. But what happens when you’ve diligently paid your premiums for years, only to have your claim denied when you need it most? A denied long-term care claim can be devastating, both emotionally and financially. This is where a long-term care attorney steps in, offering expertise and guidance to help you navigate the complex appeals process and fight for the benefits you deserve.
Understanding Long-Term Care Insurance
Long-term care insurance is specifically tailored to cover services that traditional health insurance and Medicare typically do not. This includes assistance with daily activities such as bathing, dressing, eating, and mobility, whether at home or in a specialized facility. The goal is to provide financial support for individuals who require ongoing care due to chronic illnesses, disabilities, or cognitive impairments like Alzheimer’s disease.
Policies can vary widely in terms of coverage, benefits, and eligibility requirements. You’ve been paying your premiums with the expectation that your insurer will fulfill their obligations when the time comes. Unfortunately, insurance companies may deny claims for various reasons, leaving policyholders and their families in a difficult position.
Why Claims Get Denied
Understanding why a claim might be denied is the first step in addressing the issue. Often, it’s due to incomplete or incorrect paperwork. Filing a claim involves substantial documentation, and missing information or errors can lead to delays or outright denials. Sometimes, disputes arise over the interpretation of policy terms. Insurance policies are often filled with complex language and stipulations, leading to disagreements about covered services, benefit triggers, or waiting periods.
Insurers may also question whether the level of care requested is medically necessary or if the policyholder meets the criteria for benefits. Even unintentional late premium payments can cause issues, as the insurer may assert that the policy lapsed, thereby nullifying it. Pre-existing conditions can become a point of contention during the claims process if the policy has specific exclusions. In some cases, the insurer may allege that the policyholder provided false information during the application process, accusing them of fraud or misrepresentation.
The Role of a Long-Term Care Attorney
This is where a long-term care attorney comes into play. Specializing in the nuances of insurance law, elder law, and the specific regulations governing long-term care policies, their primary role is to advocate on your behalf. They work to ensure that the insurance company fulfills its contractual obligations.
An attorney will meticulously review your insurance policy and the denial letter to identify the exact reasons for denial and determine the best course of action. They understand the formal appeals processes of insurance companies, which can be complicated and time-sensitive. By ensuring that all deadlines are met and proper protocols are followed, they navigate the appeals process efficiently.
Gathering and presenting evidence is another critical area where an attorney can assist. This includes compiling medical records, care provider statements, and any other documentation that supports your claim. An experienced attorney knows what evidence is most compelling and how to present it effectively.
They also handle all correspondence and negotiations with the insurer, reducing the risk of miscommunication and keeping a detailed record of all interactions. If necessary, an attorney can represent you in litigation against the insurance company. While many disputes are resolved before reaching this stage, legal action can sometimes encourage insurers to settle.
How a New York and New Jersey Attorney Improves Your Chances
Engaging a long-term care attorney can significantly improve the likelihood of a successful appeal. They are well-versed in the laws that protect consumers against unfair insurance practices and can identify violations such as fraudulent faith denials or unreasonable delays. An attorney can develop a strategy tailored to your specific situation, focusing on the most effective arguments and evidence to challenge the denial.
Legal representation levels the playing field, especially since insurance companies often have teams of lawyers and adjusters. It signals to the insurer that you are serious about pursuing your claim. Moreover, dealing with a denied claim can be overwhelming, especially when you’re already coping with health issues. An attorney can alleviate this burden by handling the complex legal and administrative tasks on your behalf.
Potential Outcomes When Working with an Attorney
While every case is unique, working with a long-term care attorney can lead to several possible outcomes. The insurer may approve your claim upon receiving additional information or after recognizing errors in their initial assessment. In some cases, they might agree to a settlement that provides you with a portion of the claimed benefits.
If the case goes to court and you prevail, the insurer may be ordered to pay the full benefits. In situations where bad faith is proven, they might also have to cover interest, attorney’s fees, and punitive damages. Regardless of the outcome, having an attorney increases the likelihood of a favorable resolution.
Choosing the Right Attorney
Selecting the right attorney is crucial to the success of your appeal. Look for someone who specializes in insurance law, or specifically in long-term care claims. Experience with similar cases is invaluable. Research their reputation, including client testimonials and case outcomes. Positive reviews and a strong track record are excellent indicators of competence.
Effective communication is essential. The attorney should be responsive, able to explain complex legal concepts in understandable terms, and keep you informed throughout the process. Understand their fee structure upfront. Some may work on a contingency basis, while others charge hourly rates or flat fees. Make sure the fee arrangement aligns with your financial situation. Personal compatibility is also important; you’ll be working closely with your attorney, so it’s vital to choose someone you trust and feel comfortable with.
Preventative Measures to Reduce Denial Risks
While not all denials can be prevented, taking proactive steps can reduce the likelihood of issues. Familiarize yourself with your policy’s terms, coverage limits, and exclusions. Knowing what is and isn’t covered can help you avoid surprises. Keep detailed records of all communications with the insurer, payments made, and any changes to your policy.
Ensure that premiums are paid on time to avoid lapses in coverage. When applying for the policy, provide complete and truthful information to prevent future allegations of misrepresentation. It may also be beneficial to consult with a financial advisor or attorney when purchasing a policy to fully understand your obligations and rights.
Facing a denied long-term care claim can be an overwhelming experience, especially when you’re already dealing with health challenges that necessitate care. Insurance companies may deny claims for a variety of reasons, some of which may be unjustified or in error. The long-term care attorneys at Uscher, Quiat, Uscher & Russo, P.C. bring expertise, advocacy, and peace of mind to a stressful situation, significantly increasing the chances of a favorable outcome.
By understanding your policy, knowing your rights, and enlisting professional legal help, you can navigate the appeals process more effectively. Don’t let a denied claim deter you from seeking the benefits you’ve paid for and deserve. A qualified attorney can help you fight back, ensuring that you receive the support needed to maintain your quality of life.
Take Action Today
At Uscher, Quiat, Uscher & Russo, P.C., we understand that filing a long-term disability claim isn’t just about paperwork—it’s about safeguarding your financial well-being and maintaining your quality of life.
If your long-term care claim has been denied, don’t wait to seek assistance. Time is often of the essence due to appeal deadlines and the immediate need for care services. We will assess your case and explore your options. Your health and financial well-being are too important to leave to chance.
Empower Yourself with Knowledge
The more you know about your policy and the legal avenues available to you, the better equipped you’ll be to handle any challenges that arise. Remember, you’re not alone in this process. For over three decades, Uscher, Quiat, Uscher & Russo, P.C. has delivered client-focused representation to individuals facing conflict with an insurance company over long-term care claim denials or delays. We help our clients win their claims and have the specialized knowledge and expertise needed to navigate complex claim processes.
If you have an inkling that you or a family member is being denied benefits when your policy calls for them, contact us immediately for a complimentary review of your claim. Call 201-342-7100.
New Jersey Office