When you file a claim for long-term benefits, the last thing you expect is your benefits being denied. If this has happened to you, the best course of action is to call an insurance attorney in Miami who can help you uncover why your claim was denied. Insurance attorneys can assist you in fighting for your rights. Continue reading to discover some of the most common reasons a long-term care claim can be denied.

Costs of Long-Term Care Keep Rising

It is no secret the average cost of an assisted living facility has continued to rise. This includes additional costs such as a private room in a nursing home or the cost to hire a licensed home health care aid. This places a massive financial strain on millions of American families. As a policyholder, you expect most of these costs to be covered by your policy. Facing a denied claim causes your out-of-pocket costs to rapidly increase. 

Unfortunately, long-term care policies can be very complex and the long-term care insurance industry has become extremely regulated. Dynamic laws regarding long-term care means consumers are more likely to make a mistake, overlook a deadline, or not have all the necessary paperwork. These are just a few of the reasons a claim may be denied. Others are:

The Prior Confinement Provision

The prior confinement provision is a component found in many older-generation long-term care policies. This provision acts as an obstacle before any benefits are paid. Some of these provisions include obstacles such as, patients being required to have a prior hospitalization before benefits will be paid. Depending on the state you reside, you may be able to override this provision.  However, you may require expert legal help to do so.

Insufficient Evidence

Claiming  you do not have enough evidence or the correct documentation to defend your claim is another common reason for benefit denials. Insurance companies have the right to request as many records or documents as they deem necessary before settling your claim. Working with a long-term care insurance attorney is the best option for moving forward on a claim. 

Misunderstanding What Services are Covered

Many people who have long-term insurance policies believe they fully understand the type of care their policy covers. Unfortunately, misinterpretations are a common cause for claim denials. For example, policy holders may submit a claim for assistance with daily errands such as cooking and cleaning, only to find out the claim has been denied. Later they will learn such claims  are only valid if  activities of daily living  are listed in their policy.

A Lapse in Premium Payments

Having an unintentional lapse in payment is a common reason for the denial of a claim. If the insured person suffers from cognitive decline or experiences a sudden health crisis, it can be expected they will be unable to manage their financial affairs. An effective way to avoid this problem is to name a third-party who can be notified of any lapse in premium payments and correct the potential problem.


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