Care for aging people is expensive. If you are not receiving the benefits or coverage from a long-term care insurance policy, you may be able to recover the money you are owed and more for being treated unfairly. That money can pay for long-term care and other damages you have incurred.
A retirement community, assisted living facility, or home health aide in South Dakota can provide outstanding medical care for your loved one, but these services come with a large price tag. According to Genworth Financial, a room in a nursing home has an average annual cost of $92,378 in 2016, and a home health aide costs an average of $46,332. Many people alleviate this financial burden by purchasing long-term care insurance earlier in their lives. However, some policyholders and their family members can find themselves looking at bills and asking, “What does long-term care insurance cover?” If you are currently paying for medical care that should be covered by an insurance company, a South Dakota insurance bad faith attorney may need to investigate your case and show you how to get help paying medical bills.
What Does Long-Term Care Insurance Cover?
Like other forms of insurance, long-term care insurance involves signing a contract and paying premiums in exchange for the insurance company promising to provide the coverage outlined in its policy. Long-term care insurance covers the cost of medical care provided for extended periods of time. Typically, this care includes in-home health services or residence in an assisted living facility or nursing home.
Long-term care insurance is a popular choice for aging South Dakota residents who want to make sure they will receive care after they can no longer live independently. According to LongTermCare.gov, your loved one qualifies for long-term care if a medical professional determines that he or she cannot perform activities of daily living (ADL) that may include:
- Bathing
- Dressing
- Using the bathroom
- Moving to or from a bed or chair
- Dealing with incontinence
- Eating
These are commonly listed and fall under a benefit qualifier called “loss of functional capacity.” But, that is not the only way to qualify under most insurance policies. Some policies include a trigger or benefit qualifier called “cognitive impairment.” This qualifier requires that you need supervision or direction because of cognitive impairment. Other insurance policies do not require policyholders to meet loss of functional capacity or cognitive impairment qualifiers. Some policies only require that a medical doctor prescribe the long-term care to receive benefits, because without being in the facility, your health may deteriorate, and that is enough to qualify for benefits under your policy. This qualifier is simply called “medical necessity.”
In South Dakota, if you meet one of the qualifiers under your policy, you are probably entitled to some sort of coverage. For example, even if your policy does not appear to contain coverage for assisted living, it may still be covered under your policy because South Dakota administrative rules require assisted living coverage to be included in long-term care policies.
Some of these things are listed on the South Dakota Legislative Research Counsel’s website, which lists rules and regulations passed by the South Dakota Division of Insurance that are intended to protect consumers and policyholders.
What is Insurance Bad Faith?
Every insurance policy is a promise to provide you the coverage listed in your policy and to do so in “good faith.” Unfortunately, insurance companies do not always provide the long-term care coverage they promised in a policy. Some even make a point of finding excuses to decline your loved one’s coverage, which can benefit the company’s bottom line, even if it leaves your family with sizeable medical bills. In essence, your family may have paid insurance premiums for years, believing an insurer would cover the costs of a loved one’s future long-term care, but then be forced to pay a second time when the insurer refuses to pay those covered costs. When that happens, you may be entitled to have a court order that states the company must stop breaching the insurance policy contract and pay the benefits due.
There is further legal protection for policyholders who have been wrongly denied coverage in bad faith. If it can be proven that an insurance company acted in bad faith when denying policy benefits, the policyholder may be entitled to collect not only the benefits due in the first place but also additional compensation for the harm caused by the wrongful denial and sometimes even attorneys fees for having to file a lawsuit. In egregious cases of bad faith, the insurance company may even be liable for punitive damages.
Bad faith occurs when a company denies policy benefits without a reasonable basis for doing so, knowing there is no reasonable basis for denial or ignoring evidence that supports a claim. An insurer also might be found liable for bad faith when it fails to properly investigate a policyholder’s claim or acts solely in its own interest without giving its policyholder’s interests equal consideration. A South Dakota attorney who can recognize the breach of an insurance contract and who is familiar with insurance bad faith may be able to help you get what you need to pay your loved one’s medical bills through litigation and a financial settlement. In one of our next articles, we will list some examples of things that we have seen right here in South Dakota.
How Can an Attorney Help?
Attorneys who focus on this area of the law will help identify and obtain the coverage you have been denied. Besides that, trained attorneys can look at and help figure out if it was a coincidence that you were denied benefits, or if it was predictable because of an insurance company plan or scheme. Bad faith can be difficult to detect because it often takes a trained eye to know when a company is not upholding its side of an insurance policy. An experienced South Dakota insurance bad faith attorney can examine your family’s medical bills and compare them to the long-term care coverage you thought should be covering them. If it is a case of insurance bad faith, your attorney can initiate a lawsuit against the insurance company, not only to take the first steps toward receiving the coverage your loved one needs and deserves but also to help other consumers be treated fairly when they have similar claims.
If a long-term care insurance company is refusing to pay your relative’s medical bills in South Dakota, contact the Turbak Law Office at 605-886-8361 for a free consultation with an experienced attorney.
