Understanding and Overcoming Denied Long-Term Care Insurance Claims with American United (OneAmerica)

The American United life insurance company is one of the OneAmerica family of companies, which plays a significant role in the insurance industry. In 2003, they expanded their portfolio by acquiring the group life and disability business from The Union Central Life Insurance Company. Today, they offer a diverse range of disability insurance products to meet various needs:

Long-term care insurance is a lifeline for millions of Americans, providing financial security in times of need. In 2013 alone, approximately $7.5 billion in long-term care insurance benefits were paid out to 273,000 policyholders, marking a 13% increase from the previous year. However, despite the substantial payouts, many policyholders still find themselves facing the daunting prospect of a denied long-term care insurance claim. 


 The Rising Costs of Long-Term Care

Long-term care costs in the United States have been steadily rising, placing a significant financial burden on families across the nation. According to the Genworth 2013 Cost of Care report, the average annual cost of an assisted living facility was $41,400, while a private room in a nursing home reached a staggering $83,950 per year. The cost of hiring a licensed home health care aide also hovers around $20.00 per hour. These escalating expenses underscore the critical importance of long-term care insurance, which should theoretically cover most of these costs.

However, when a long-term care insurance claim is denied, policyholders are left to shoulder these expenses on their own, potentially leading to financial hardship. If you find yourself in this situation, it’s crucial to seek assistance promptly.

 The Complexity of Long-Term Care Insurance

Long-term care insurance policies are complex and highly regulated, making it essential for policyholders to have a clear understanding of their coverage and the legal framework that governs it. The intricacies of these policies, coupled with evolving regulations, often create scenarios where claims are denied. Below are some common reasons for these denials:

  1. The Prior Confinement Provision

Many older-generation long-term care insurance policies contain a prior confinement provision, which requires an insured individual to have had prior hospitalization confinement or a nursing home stay before benefits will be paid. It’s important to note that many states have prohibited such provisions, but their enforceability varies. Seeking expert guidance is essential when dealing with policies containing this provision.

  1. Insufficient Evidence or Documentation

A frequent cause of denial is insufficient evidence or documentation. Insurance companies require comprehensive records to determine claim eligibility. Inadequate or poorly documented information can lead to a claim being denied. The requirements for coverage can be quite specific.  Your proof must be carefully tailored to policy standards and definitions. To increase your chances of approval, ensure you provide strong supporting evidence to substantiate your claim. A long-term care insurance attorney can assist you in this process.

  1. Misunderstanding Covered Services

Policyholders often misunderstand which services are covered under their policy. Submitting a claim for personal care services without proof of assistance with daily living activities, as specified in the policy, can result in denial. It’s essential to fully comprehend the scope of your coverage before submitting a claim.

  1. The Benefit Eligibility Assessment

Insured individuals may undergo periodic assessments by insurance companies to determine ongoing eligibility for benefits. Misunderstanding the implications of these assessments and understating health issues can lead to claim denials. It’s critical to grasp the purpose of these assessments, and a long-term care insurance attorney can help explain them.

  1. Lapses in Premium Payments

Unintentional policy lapses are preventable but still occur, often due to cognitive impairment or sudden health crises preventing individuals from managing their finances. Naming a third-party addressee can provide an extra layer of protection against unintended lapses. State laws vary in their protection of vulnerable seniors in such situations, and an attorney can help navigate these complexities.

 Steps to Take If Your LTC Claim Has Been Denied

Facing a denied long-term care insurance claim can be distressing, but there are steps you can take to address the situation:

  1. Learn The Reason For The Denial

Gather information to understand why your claim was denied. Insurance companies are obligated to provide this information, and our legal team can assist in deciphering the reasons behind the denial.

  1. Request An Appeal

After identifying the reasons for the denial, initiate the appeals process as per your insurance company’s guidelines. It’s crucial to address the root causes of the denial to increase your chances of a successful appeal. Our attorneys can guide you through this process.

  1. Schedule A Consultation With A Long-term Care Insurance Claim Attorney

Navigating the complexities of long-term care insurance can be challenging. A consultation with an experienced attorney is invaluable in understanding your policy and addressing claim issues. Our compassionate attorneys have extensive experience in handling long-term care insurance disputes and can provide expert guidance.

Why You Need a Long-term Care Insurance Claim Attorney

The attorneys at Robinson & Warncke have over three decades of experience assisting clients and their loved ones with their long-term care insurance claims. A long-term care insurance denial can impose significant emotional, financial, and physical burdens on policyholders and their families. An attorney can advocate on your behalf, ensuring you receive the care and benefits you deserve.

 Frequently Asked Questions

What are some of the top reasons for needing long-term care?

While some individuals require long-term care insurance benefits due to injuries, the majority qualify through age-related disability or cognitive impairment. As Americans live longer, the impact of a long-term care insurance denial on their quality of life becomes increasingly significant.

How does a person meet long-term care insurance eligibility requirements?

Eligibility for long-term care insurance benefits typically requires assistance with daily living activities or cognitive impairment. The specific criteria vary by policy, but most policies consider activities like feeding, bathing, dressing, toileting, and transferring. Understanding your policy’s definition of “assistance” is crucial.

Can insurers cancel a long-term care insurance policy?

Long-term care insurance policies are guaranteed renewable, meaning they cannot be canceled except for non-payment of premiums. Even in cases of non-payment, policy reinstatement may be possible, especially in instances of unintentional lapses due to cognitive impairment or health crises. Consult with Robinson & Warncke if you face a policy lapse.

In conclusion, navigating the world of long-term care insurance can be daunting, especially when faced with a denied claim. Seeking professional guidance from experienced attorneys like Robinson & Warncke is the key to understanding your policy, addressing claim issues, and securing the care and benefits you deserve.