Experienced attorneys fighting for your long term care benefits

Long-term care insurance — which can be individually purchased, offered as a self-paid employee benefit option, or (for the fortunate few) provided as an employer-funded employee benefit — can be an invaluable resource for those in need of home care or residential care. Insurers can be strict in interpreting eligibility for benefits, however, and we have encountered incidents of arbitrary and improper claim denials. Our experience with medical and disability insurance has positioned us well to provide assistance with long-term care benefit claims and claim denials. We have assisted clients with long-term care coverage from many of the major insurance providers. Major long term care insurers include Mutual of Omaha, Unum, Brighthouse, IDS Life Insurance, Riversource, Provident Life, Paul Revere, John Hancock, Prudential, Continental General, Genworth Life, John Alden, Nationwide, MetLife, New York Life, Transamerica Life, Continental Casualty (CNA), Pioneer, and Berkshire Life.

Long Term Care Coverage

Long Term Care coverage can be made available by an employer or individually purchased. Typically, such coverage will provide benefits for various forms of long term care: long term care at a residential facility, nursing home, or assisted living facility; adult day care at a community-based program/facility; or care provided in the home (such as by a visiting nurse service, a home healthcare agency, or a hospice program). Benefits may be paid at a daily fixed rate, or may be based solely on expenses actually incurred by the claimant. Covered expenses may include: room and board; visit charges by nurses and home health aides; home health management fees for establishing and supervising a care plan; home modifications or installation of home devices that assist with safety and/or activities of daily living; care training for family members or other informal caregivers; etc.

Some common long term care claim issues

Our attorneys can provide guidance with regard to frequently recurring questions and disputes involving long term care claims. Before a claim is filed, there may be questions regarding coverage requirements, benefit limitations and exclusions, and the procedures for filing a claim, such as:

• Do I have to go through an elimination period (waiting period) before I am entitled to receive benefits? Will it depend on the kinds of services I’m receiving?
• Is my coverage subject to a pre-existing condition limitation or exclusion and, if so, will that prevent me from receiving benefits?
• Do I need to hire and pay home healthcare providers in order to be eligible for home healthcare benefits (or is it enough if I require such care, but it is provided informally by friends or family)?
• Is my illness or injury severe enough for me to receive long term care benefits? What are activities of daily living (ADLs), and can I demonstrate that I qualify for benefits? Do I need to receive care every day, or can I qualify for long term care benefits if I can get by with less-frequent home care assistance? Can I qualify for benefits if I’m suffering from cognitive deficits or dementia that make it difficult for me to reliably care for myself or make it dangerous to be without supervision?
• Must my care be provided through a home healthcare agency, or can I hire a nurse or home health aide on my own? Must my doctor first approve the care or set up a care plan to qualify for benefits?
• Must the home health aide or nurse have any particular certification — by the state or by the insurance company — in order for me to be reimbursed for their services? Must a long term care or assisted living facility be licensed or certified in some way for me to receive long term care benefit payments for care received in such a facility?
• When do I need to notify my insurance company that I may be entitled to long term care benefits, and when should I file my claim forms?
• Should my primary doctor or my specialist fill out the physician forms?
• How long will it take for my claim to be approved?
• Will payments be made to me, or can my long term care facility or home health agency submit bills directly to my insurance company?

Once a claim is filed and/or approved, different questions may arise:

• How often will I need to re-qualify for benefits, and what kind of ongoing paperwork will I need to provide to my insurer to receiving continuing long term care benefits?
• Does my policy have benefit maximums?
• If I am receiving benefits for a home health aide that assists me in my home, but I am subsequently hospitalized, will my long term care policy provide coverage for the home health aide to provide me assistance in the hospital?
• My insurance company has asked me to be examined in my home by a nurse, or to undergo a neuropsychological assessment, or to participate in an independent medical examination, should I be worried?
• Is there anything I can do to ensure that the evaluation or examination is conducted fairly and by an appropriately qualified medical professional?
• If I’m receiving benefits in a long term care facility, but need to be hospitalized for an acute illness, will my long term care insurance cover the cost for reserving my bed at the facility until I am discharged from the hospital?
• My insurer denied my claim based on unfounded allegations of fraud with regard to the claim, or purported misstatements on the policy application — what are my legal options for fighting this?

Our lawyers can help you answer these questions and ensure that you receive the long term care benefits to which you are entitled.

Long term care insurance services

At the Law Office of Mark Scherzer, our lawyers provide disability claim assistance at every stage:

• Assistance with applying for long term care benefits and preparing initial proof of claim forms — Our lawyers can provide assistance in completing your claim forms to ensure that you have the best chance of being approved for long term care benefits.
• Assistance with supplemental claim forms — If your claim has already been approved, but your insurer is requiring updated forms, our attorneys can guide you in the completion of any such supplemental reports to best ensure your that your long term care benefits continue without interruption.
• Responding to insurance company demands for independent medical examinations, at-home field interviews, etc. — Your insurance company may question the severity of your condition (and your entitlement to benefits), and, consequently, may ask that you participate in an Independent Medical Examination (IME) or in an interview at your home by a field examiner or nurse. Our attorneys can evaluate whether these requests are reasonable, provide guidance, and, if necessary, intervene to ensure that any such evaluation is conducted fairly and in a manner that fully protects your rights.
• Appealing long term care claim denials or long term care benefit terminations — When a long term care claim is denied, or a previously approved claim is terminated, there is often an appeal process that is available (and, in some circumstances, may be mandatory). It is very important to consider retaining an attorney to manage the appeal process, as discussed in more detail on our webpage, “Consulting an Insurance or ERISA Lawyer.”
• Enforcing your rights to long term care benefits through a lawsuit — In the event of an  unsuccessful appeal (or where an appeal is not mandatory), a lawsuit may be your only remaining option to enforce your entitlement to long term care benefits. As discussed in greater detail on our webpage, “Filing a Lawsuit: Taking your Insurance Company to Court,” our attorneys have litigated in state and federal courts, and are well-prepared to commence a lawsuit against your long term care insurance company and secure payment of the benefits that you deserve.

TELEPHONE:  212-406-9606

Mark Scherzer Law :: Long-Term Care Benefit Attorneys :: Disability Lawyers :: Long-Term Care Claim Assistance and Planning
New York Long-Term Care Benefit Lawyers (including New York City, Long Island, Hudson Valley, Capital District, North Country, Mohawk Valley, Finger Lakes, Southern Tier, Western New York, and Central New York)