More and more people are purchasing long-term care insurance to help pay for daily expenses related to disabilities or chronic illnesses. Although this insurance helps reduce the amount that an elder has to pay out of pocket, there are some pitfalls.
Coverage denial is not uncommon, and sometimes there are legitimate reasons for them and sometimes there are not. It is important for individuals to understand what their policy covers and to appeal denials if there is no good reason for them.
Long-term care insurance basics
According to AARP, long-term care insurance covers long-term expenses that employer-sponsored health insurance and Medicare do not cover. These expenses include extended stays at a nursing home or assisted living facility, or costs related to at-home care. Insurance may cover skilled care as well as daily activities like bathing, eating and dressing. Some policies also cover services such as care coordination or adult day care.
Common denial reasons
Every policy is different, and a denial may be due to coverage exceptions. For example, many policies do not cover pre-existing conditions. If your claim involves care for a condition from the past, the insurance company may deny payment. Some policies also only allow care from professional, certified caretakers, so a denial may occur if you get care from a non-licensed individual. Your policy may also not cover certain services, which would result in a claim denial.
According to the Washington State Office of the Insurance Commissioner, some other reasons for claim denial include:
- The care occurred in a healthcare setting not approved by the policy
- The treatment was not medically necessary
- There was a lapse in coverage due to lack of payment
If you can submit evidence that your claim is valid, it is worth fighting the denial decision and filing an appeal.
