Long Term Care Insurance and Home Health Care

Medicare may not cover long-term care other than for short durations, and unless the needy person has no assets or source of income, he or she will not qualify for Medicaid, which may also cover long-term care on a limited basis. Consequently, long term care must be paid for out of pocket unless one qualifies for Veteran’s Aide and Attendance Benefits, or carries Long Term Care Insurance. In the case of long term care insurance, the insurance industry has targeted a lucrative market in the elderly and aging baby boomers, many of whom may require long-term care in later years when they became incapable of providing for their own needs including bathing, dressing, ambulating, feeding, transferring, and general supervision. Nursing home care, assisted living as well as home care assistance are covered by long-term care policies.

This type of insurance is critical because it helps to absorb the prohibitive costs of long term care. Because the insurance policy is a contract, an insured person must understand the nuances inherent in policies in general and specifically long term care policies.  Confusing policy language and overwhelming paperwork along with other tactics are undertaken on the part of some insurance companies to deny or delay claims. Those companies benefit from the elderly person’s incapability to understand the policy, lack of will to fight for their claim, and inability to persist in order to be rightfully paid. After years of paying premiums, many seniors give up, thinking there is no recourse.

Florida Law protects you in two ways:

First, it requires insurance companies to offer and provide specific c overages, and has strict rules for when an insurance company can terminate a policy for non-payment of premiums.

Second, if the policy language is subject to more than one interpretation, the court must interpret it in your favor. It takes full knowledge of the law, and full understanding of these policies to be able to effectively enforce your rights. At the Law Offices of Steven M. Dunn, P.A., we have shifted our focus to meet the rising demand for representation of persons challenged by long term care denials. To date we have handled well over 500 cases involving long term care insurance policies. Examples of long term care claims we have handled:

A lawsuit was brought on behalf of a client against Fortis/John Hancock Insurance Company for failing to honor long-term care coverage for an assisted-living facility. The denial was based on an arbitrary interpretation by the insurance company of what a “home healthcare agency” is concluding that an assisted living is not a covered provider. However, the policy contained no definition for “home healthcare agency”. The court held the policy was ambiguous and ruled that the assisted living facility could be deemed a home healthcare agency and therefore could be a covered provider of care. Therefore, the policy did cover the cost of the assisted Living Facility.

A lawsuit brought on behalf of a client against Blue Cross and Blue Shield of Florida for failing to honor long term care coverage for a man who was forced to enter an assisted living facility. The insurance company denied coverage based on a provision in the policy that denied benefits if the care was provided in an “institutional setting” and that an assisted living facility was an institution. The court held that the term “institutional setting” was ambiguous, and found that the company had to cover the care. The insurance company unsuccessfully tried to use fuzzy language to deny benefits to someone who had paid premiums for years and desperately needed the care. Without that ruling, all of the premiums the insured person paid would have been wasted, and the policy rendered worthless.

A class action lawsuit was brought against Washington National Insurance Company for failing to apply an 8% inflation rider to all of the benefits under the policy. The federal court ruled that the policy is ambiguous. As a consequence of this case, many elderly Floridians were reimbursed for out of pocket care, and were placed back on claim by the insurance company.

A lawsuit was brought challenging Continental Casualty Insurance Company’s requirement that in order for a person to receive needed home care benefits, they must first receive at least one skilled visit from a nurse, therapist or similar such provider regardless of whether the skilled visit was needed. The court appellate court issued a scathing opinion that is extremely important because it recognizes the strong public policy in Florida in favor of the elderly and the need for long term care insurance coverage to provide benefits without unreasonable barriers. See Bell Care Nurses Registry v CNA

Get Legal Help

Because insurance policies are noted for their complexity, and the average policy holder has difficulty understanding the coverage provided, it is wise to have an attorney review the policy to protect your rights. Insurance companies employ adjusters and retain their own attorneys to interpret insurance policies in their favor. They reduce or deny benefits, whenever possible.

At Steven Dunn, P.A., we will manage or negotiate your initial claim, appeal an improper denial of claim on your behalf, or litigate against the insurance company if necessary to enforce your rights. In addition, if your insurance claim has been unjustly denied, our firm may be able to obtain compensation not only for policy benefits, but also for other losses incurred, such as emotional distress and general damages, lawyers’ fees, and other out-of-pocket expenses. In extreme cases, the court may even award punitive damages. To view the long-term care blog click the following link: www.longtermcarelawoffice.com/blog/.

To discuss your insurance concerns and determine if you have a well-founded claim, contact the Law Office of Steven M. Dunn, P.A. online or at 305-868-1400.