Wrongful Denial of Benefits for Long-Term Care

Jan 17, 2019 | Blog |

Though many policyholders forget, it’s important to recognize that insurers are always looking to maximize their profits — and this typically involves a strategy of minimizing their expenses by developing policies that justify the denial of seemingly legitimate claims.  The easier it is to justify the denial of an insurance claim, the less likely it is that the policyholder will challenge the decision.  This enables the insurer to avoid having to payout for claims that are actually recoverable.

Long-term care insurance policies are no exception to this rule.  In fact, long-term care can be quite expensive for an insurer to cover, and as such, denials are common.  Policyholders who have purchased insurance coverage for their long-term care (i.e., benefits that cover nursing home costs, costs of assisted living, etc.) may find that the policy is written in an ambiguous manner or that the insurer uses “slippery” tactics to avoid having to payout.

Let’s explore some basic issues.

Ambiguous Provisions Must Be Interpreted to Favor Coverage

Insurers in the long-term care context often write ambiguous contract terms and provisions that are then used to justify the denial of benefits.  Fortunately, Illinois law is protective of the policyholder in this regard — if an insurance contract provision is legitimately ambiguous, then the courts must interpret it in a manner that favors coverage.

For example, if it is not clear whether your long-term care policy covers the expenses accrued by staying at nursing home facilities, or only home care, then the court will construe the ambiguous provision to be more expansive (covering nursing home facilities).

Definitional Issues

Facility-Based Care vs. Home Care

Among the many points of conflict in long-term care policies is whether the coverage extends to facilities (i.e., nursing homes) or whether it only applies to expenses accrued for long-term home care, such as assisted living services provided by an on-call caregiver who visits one’s residence throughout the day/week.

Medical Necessity vs. Activities of Daily Living

Generally speaking, long-term care policies activate when the policyholder is unable to engage in their “activities of daily living,” however that is defined in their contract.  What activities constitute “activities of daily living” is a potential coverage issue in and of itself.  Some policies are much more restrictive, however, and only activate when long-term care is medically necessary for the policyholder (for example, in a situation where the policyholder needs to be put on a respirator and provided care due to paralysis).

Contact an Experienced Chicago Insurance Attorney for Help With Your Claims

Here at the Bryant Legal Group, P.C., our team of attorneys has decades of experience representing the interests of policyholders involved in a wide range of disputes with their insurers, including conflicts that center around the wrongful denial of a long-term care insurance claim.

Long-term care claims can be quite complex, given the vulnerability of the policyholder (who may lack the physical, emotional, and financial wherewithal to push a comprehensive challenge).  As such, it’s important that policyholders seek out the assistance of attorneys who have a consistent track record of success in handling such disputes, and are capable of doing so in a manner that is respectful of the policyholder’s specific goals and limitations.

Ready to speak to an experienced Chicago insurance attorney about your long-term care dispute?  Call 312-634-6415 or send us a message through our Contact Us page to request an appointment today.

Bryant Legal Group - Chicago Healthcare and Disability Attorneys

Testimonials

"Mr Bryant, his partner Jennifer Danish and associate Steve Jackson were efficient, diligent and persistent towards finding a just resolution and favorable outcome for myself and my entire company."

"I used Jennifer Danish for a disability claim. Frustrated that I couldn’t get results myself I found her. She unearthed some issues my doctor did Not notify me of that affect the quality of my life. My end result was positive!"

"Mr. Jackson did an outstanding job in relation to my case. He insured I was. Both prepared as well as informed regarding the hearing. I would highly recommend his skills and personal dedication to the client."

"Though difficult for the obvious reasons, your involvement has made this process infinitely more tolerable. Please know of my sincere appreciation for your efforts. With Very Best Regards,"

Contact Us For A Free Consultation

Contact Us Now

Please note: We are not accepting any new Social Security disability cases unless paired with a long term disability insurance claim or disability pension claim.

Bryant Legal Group PC Bryant Legal Group PC

Location

205 N Michigan Ave,
Ste 3910

Chicago, IL 60601

Email: Info@bryantlg.com
Main Line: 312-561-3010
Fax: 312-254-3140

Free Consultation