Long-Term Care Insurance and Home Health Care Insurance
Assisted Living Facility care, Nursing Home care, as well as Home Healthcare assistance are services that can and should be covered under Long-Term Care Insurance policies. To be sure, the costs of Long Term Care and Home Care are overwhelming and can deplete a person's life savings very quickly. Therefore, denials by the insurance companies can and do cause families to undergo perhaps the greatest challenges they might ever have to face-how to get adequate care for their parents and grandparents and how to pay for it.
Insurance Companies operate for profit. The profits are derived from the premiums you pay less the expenses of operating the company, including salaries of the officers and employees of the company, and finally the claims they have to pay out. The less they pay in claims, the more profit they make. It is that simple. Consequently, there is always tension between the insurance company's duty to act in good-faith towards its insured when it receives a claim, and its drive to maximize profits. For a person who has paid insurance premiums faithfully for many years in order to protect against a financial loss, to be met with resistance and denials at a time of need creates pressure and a vulnerability no one should ever have to endure.
This is particularly so in the field of Long-Term Care Insurance where the person in need is not only infirmed, but usually elderly and completely at the mercy of the insurance company. Confusing policy language and overwhelming paperwork, along with other tactics, are undertaken on the part of insurance companies to deny or delay claims. Insurance companies benefit from the elderly person’s inability 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 and their families simply give up, thinking there is no recourse. Let us assure you, there is.
Florida Law protects you in three ways:
1. The law requires insurance companies to offer and provide specific coverages, and has strict rules for when an insurance company can terminate a policy for non-payment of premiums;
2. If the policy language is subject to more than one interpretation, the court must interpret it in your favor; and
3. If you win, the insurance company must pay attorney fees and court costs.
We fight to make sure you receive the benefits you are entitled to. Examples of Long-Term Care Insurance claims we are currently handling or have concluded include:
- A lawsuit brought on behalf of a client against Fortis 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 that excluded Assisted Living. The policy contained no definition for “Home Health Care Agency”. Hence, there were limitations for dis-allowance of policy benefits. The court held the policy was ambiguous and ruled that the, policy did cover the cost of the Assisted Living Facility.
- A motion for summary judgment in 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 has ruled that the policy is ambiguous and the the complaint states a valid claim for breach of contract because of the insurer's failure to apply the rider to all of the benefits.
- A lawsuit was brought challenging Continental Casualty Insurance Company's (CNA) 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 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 www.3dca.flcourts.org/Opinions/3D08-2226.pdf
Get Legal Help
Insurance policies are noted for their complexity, and the average person has difficulty understanding the coverages provided and exluded. Therefore, 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, and they use the self serving interpretations to reduce or deny benefits.
At Steven Dunn, P.A., our lawyers 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 help you maintain your financial security. 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.longtermcarelawyer.blogspot.com/.
For a free consultation, contact the Law Office of Steven M. Dunn, P.A. online or at 305-868-1400 or toll free at 1-888-576-9076.
