Frequently Asked Questions
Florida Lawyers - Long-Term Healthcare
- What is long-term healthcare insurance?
- What is long-term disability insurance?
- Does an insurance company have the right to deny your claim?
- What is insurance bad faith?
- What can you do if an insurance company refuses to pay your claim or denies a benefit or unjustly terminates your policy?
- What types of insurance cases are represented by our firm?
- If you are an elderly person requiring health care or are disabled and unable to work, what should you do if your insurance company is delaying payment?
- How do you pay for an attorney if you are a retired elderly person or disabled individual who cannot work or cover expenses?
- Do nurse registries or home health agencies have any rights under long-term care insurance policies that cover the customer?
- Do long-term care "home" policies cover care received in an assisted living facility?
1. What is long-term healthcare insurance?
Long-term healthcare insurance is private insurance that covers benefits to individuals who require long-term care based on illness or disabilities that prevent them from managing daily living activities. Assistance with eating, bathing, and household chores (in instances of in-home care, through caregivers) are provided by the insurance policy. The services may extend to nursing home facilities, assisted living or home healthcare and may involve medically skilled, intermediate or custodial care. Long term health care insurance would cover costs not generally covered by Medicare or Medicaid.
2. What is long-term disability insurance?
Persons disabled through illness or injury who have long-term disability insurance receive income protection if their disability based on an inability to work. This type of insurance generally covers 40% to 60% of the individual’s gross income, and may be non-taxable. There is usually an initial waiting period, called an elimination period, before the policyholder can apply for benefits. If you have long-term disability insurance, an experienced personal injury lawyer can review your insurance policy and assist you in obtaining all the benefits you are entitled to receive, ensuring you apply correctly.
3. Does an insurance company have the right to deny your claim?
If your claim does not correspond to the conditions of the insurance policy, if you have not adhered to the policy’s terms, or if the insurance carrier believes your claim is fraudulent, the company has the right to deny your claim. Unfortunately, it is not uncommon for insurance companies to interpret legitimate claims based on negligible factors or tricky policy language so they can deny the claim or terminate benefits.
4. What is insurance bad faith?
An insurance company has the responsibility to its policy holders to deal with claims in good faith. When the insurance company breaches its contract with the insured by not honoring a legitimate claim, insurance bad faith may be said to have occurred. The following insurance practices are considered insurance bad faith:
- Unreasonable delay of claims
- Denial of legitimate claims
- Underpayment of legitimate claims
- Termination of legitimate claims
- Use of vague or confusing terminology in the policy to misrepresent benefits
- Placing company profits over delivery of policyholder benefits
- Concealment of benefits from the insured
- Disfavoring claims through intimidation
- Use of intimidation to under-settle claims
- Compelling the policyholder to file a lawsuit before payment of benefits
5. What can you do if an insurance company refuses to pay your claim or denies a benefit or unjustly terminates your policy?
Most insurance carriers require a policyholder to file an appeal or grievance within a specified number of days, including short periods of time such as 15 to 60 days. Lawsuits are generally not permitted until after the appeal or grievance process has been exhausted, as explained under the insurance plan or policy. Because insurance companies often employ legal tactics which favor their company, it is wise to have an experienced lawyer review your claim to ensure you are meeting the appeals process requirements. Arbitration may be required by the policy. There are often multiple levels of appeal that must be undertaken within stipulated time limits. Your medical treatment may be being disallowed as experimental and various other approaches that are quite complicated may be in play, all designed to discourage and result in denial of the claim.
6. What types of insurance cases are represented by our firm?
Our firm represents clients in long term healthcare and long term disability claims that have been wrongfully denied. We also handle uninsured/underinsured motorist claims, homeowner claims, and business loss claims.
7. If you are an elderly person requiring health care or are disabled and unable to work, what should you do if your insurance company is delaying payment?
Obtaining a lawyer experienced in dealing with denied or delayed long term health care or long term disability insurance claims is your best recourse for receiving insurance benefits. Through a lawsuit, the court may order short term payment or you may have to wait until the lawsuit is settled or until the court rules on your case. Even so, damages awarded may not only pay for benefits, but may also exceed the benefits owed by covering additional damages based on insurance bad faith.
8. How do you pay for a lawyer if you are a retired elderly person or disabled individual who cannot work or cover expenses?
Our lawyers will review your policy to determine whether you have a case against the insurance company. Based on case evaluation, we may represent you on a contingency basis, meaning that unless we recover compensation on your behalf, you would owe no attorney fees. After winning your case, our fees would be based on a percentage of the recovery, or the court may order the insurance company to pay some or all of your attorney fees.
9. Do nurse registries or home health agencies have any rights under long-term care insurance policies that cover the customer?
If care is given under an assignment of benefits, the the registry or home health agency stands in the shoes of the insured, and has the same rights as the insured. Therefore, if invoices are denied by the insurance company, the registry and agency can sue directly, and if they prevail, they can recoup their attorney fees and costs. Therefore, it is critically important to have a properly drafted assignment, and understand what the coverages are. We can help draft those documents, advise on the coverages, and ultimately collect those invoices.
10. Do long-term care "home" policies cover care received in an assisted living facility?
Under Florida Law, an Assisted Living Facility is considered to be a persons home. Therefore, a policy that seeks to exclude Assisted Living Facilities from the definition of home is illegal. Furthermore, an insurer that denies home care rendered by a registry or agency to a person living at an Assisted Living Facilitly is doing so contrary to the law.
