Receiving a rejection in a long-term care insurance claim - How to fight insurance companies

 (photo credit: YANIR HAREL & CO. LAW OFFICE & NOTARY)
(photo credit: YANIR HAREL & CO. LAW OFFICE & NOTARY)
 
Public awareness of the phenomenon of rejecting long-term care insurance claims is rising year by year due to the problematic conduct of insurance companies. In many cases, long-term care insureds find to their surprise that precisely when they need the backing of long-term care insurance, insurance companies pile many difficulties on them, delaying the clarification of the claim and even reject long-term care insurance claims for reasons that are difficult to agree with.
In light of the difficult conduct of insurance companies in the clarification procedures of long-term care insurance claims, it is important to know what tools insureds have to combat the rejection of long-term care insurance claims and succeed in exercising their full insurance rights.
First of all, it is important to understand when the insured in long-term care insurance has the right to receive the insurance benefits by virtue of the long-term care insurance policy. In short, in order to receive the insurance benefits, the full conditions of the "insurance case" as defined in the policy must be met. It is important to understand that a policy is a legally binding contract, and in order to receive the insurance benefits the insured must meet the binding requirements of the policy. Most long-term care insurance policies state that the insurance case exists if the insured meets the following definitions:
If an insured needs substantial help (unable to perform at least 50% of the activity on his own) of at least 3 of the following 6 ADL (Activities of Daily Living) actions: getting up and lying down, getting dressed and undressed, bathing, eating and drinking, continence and mobility.
If an insured is in a state of "mental exhaustion," which manifests itself in cognitive impairment that includes impaired insight and judgment, decreased long-term or short-term memory, lack of orientation in place and time, and supervision is required most of the day, and the mental state is determined by a specialist doctor and be linked to diseases such as Alzheimer's, or dementia.
It’s important to know: There are lenient insurance policies that require substantial assistance in performing only 2 out of 6 activities, but there are also stricter policies that require substantial assistance in performing 4 out of 6 activities.
The right to receive the insurance benefits is not immediate, even if the insured fulfills the full conditions of the policy. Most long-term care insurance policies have waiting periods of 60-90 days. The waiting period means the period of time that must be waited before the insured is entitled to the insurance benefits for a qualifying long-term care condition. The waiting period starts from the date of the occurrence of the insured event, meaning an insured who meets the definition of the insured event is entitled to a long-term care benefit from the date he was defined as a long-term care individual according to the terms of the policy, but will receive payment only from the end of the waiting period.
Regrettably, the reality is that insurance companies reject many claims of long-term care insurance policyholders. These rejections are based on the insurance companies' interpretation of medical documents as well as in light of medical findings by experts on their behalf. Other cases of rejection lie in the legal interpretation of the insurance companies' terms of the policy.
If a rejection is received, do not give up! The reasons for the rejection by the insurance company should be carefully examined, and advice should be obtained from physicians who specialize in long-term care situations as well as from a lawyer who specializes in representation in long-term care insurance claims.
There are many cases where insureds have asserted their rights and the insurance company has agreed to change its position in full or in part, so it is very worthwhile to insist and stand up for your rights.
In order to be successful in a claim against the insurance company, you must have the following documents: the insurance policy, an insurance details page, a full and detailed rejection letter and the long-term care assessment on behalf of the insurance company.
The medical documents must also be located from the date on which the insured claims to have become a long-term care individual, indicating the limitations that indicate a long-term care condition. If the insured has been recognized as a long-term care individual by the National Insurance Institute, it is important to obtain the documents of the medical committee that took place and examined his long-term care condition. It is important to know that although recognition by the NII does not obligate the insurance company but it can certainly support the claims of the insured, and the insurance companies certainly give it significance.
Even if a long time has passed since the date of receipt of the rejection of the long-term care insurance claim, there is something that can be done. It is important to know that an insured who meets the definitions of a long-term care condition is entitled to claim benefits retroactively from the date of the insured event as defined in the policy for a period of three years back. This means that insurance benefits can be received for a period of three years from the date of the insured event.
In addition, it should be noted that there is a shortened statute of limitations in long-term care insurance claims of only three years - except for policies signed or renewed after the entry into law of Amendment 11 to the Insurance Contract Law 5720-2020, i.e., after November 25, 2020, and then the limitation period is five years.
Please remember that the statute of limitations is counted from the date of the occurrence of the long-term care insurance case, so it is recommended not to delay and seek clarification of the insured's rights and thus receive the long-term care insurance benefits.
Those who are not sure which long-term care insurance policies they have, can check the Har Habituach website of the Finance Ministry, where they can enter their ID details with the date of issue to find out what insurance policies exist for the person in his / her name, including long-term care insurance policies.
It is emphasized that the courts and the Office of the Supervisor of Insurance have established guidelines and conditions that are binding on insurance companies with regard to the clarification procedures for long-term care insurance claims. These guidelines and conditions are not known to most of the insured in long-term care insurance policies and this lack of familiarity may result in a real violation of their rights.
Of course, getting professional advice from a lawyer who is well versed in the rules and conditions required for approving a long-term care insurance claim can significantly improve the chances of success of the claim. For example, the binding condition that for any ADL activity it is sufficient that the insured is 50% incapacitated when doing the activity (according to the Supervisor of Insurance circular from 2013) and similar arrangements, procedures and other rulings in connection with long-term care insurance.
Summary:
• Insurance companies often reject without justification or out of error of claims of long-term care insurance policyholders.
• There is a lot to do in case of dismissal of a long-term care insurance claim and it is not adviced to give up!
• Professional preparations must be made to deal with the insurance company. Remember to demand documents that you have a right to receive and get professional advice.
• It is highly advisable to consult a professional lawyer who specializes in long-term care insurance and to benefit from his experience and accumulated knowledge.
Adv. Yanir Harel writes legal articles and weekly news updates from Israeli court rulings.
Adv. Yanir Harel is the author of the leading book "The Law of Evidence in Insurance Claims and Car Accidents."
The law firm of Yanir Harel & Co. has proven successes and in-depth professional knowledge in representing policyholders in long-term care insurance claims.
Contact details: Tel. 03-776-5017 Fax. 03-776-5018
Email. Office@yhc-law.co.il