Long-Term Care Insurance and Home Health Care

Medicare may not cover long-term healthcare, and unless the elderly person has no assets or source of income, he or she will not qualify for Medicaid, which may cover long-term care for the destitute on a very limited basis. Consequently, the insurance industry has targeted a lucrative market in the elderly and aging baby boomers, many of whom may require long-term healthcare 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 healthcare assistance are covered by long-term care policies.

The insurance industry, in order to turn a profit, relies on the fact that most policy holders never file insurance claims. In contrast to their usual operating basis of a low percentage of filed claims, with the baby boomer market, a large percentage of policy holders are filing long-term healthcare claims, which creates problems for insurance companies. 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 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:

1. First, it 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. Second, if the policy language is subject to more than one interpretation, the court must interpret it in your favor.

So, 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., our attorneys have shifted our focus to meet the rising demand for representation in long term health care claims among the elderly living in Florida.  We have the skill and experience to make sure you receive the benefits you are entitled to.  Examples of long-term healthcare claims we are currently representing include:

• A lawsuit brought on behalf of a client against Fortis Insurance Company for failing to honor long-term healthcare coverage an assisted-living facility. The denial was based on an arbitrary interpretation by the insurance company of what a "home healthcare agency" is that disallowed assisted living. The policy contained no definition for “home health are agency” and therefore set no limitations for disallowance. The court held the policy was ambiguous. Therefore, 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 healthcare 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 Washinton National Insurance Company for failing to appliy an 8% inflation rider to all of the benefits under the policy. The federal court has ruled that the policy is abiguous 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 Casuality 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 stong 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

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., 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 obtain your financial security. When represented by a seasoned insurance trial lawyer with extensive experience in representing disability, long-term healthcare, uninsured motorist, homeowners, business, and other types of insurance claims, your likelihood of obtaining the benefits you deserve are much greater.

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/

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 or toll free at 1-888-576-9076.