Coal Miner’s Long Term Care Insurance Bad Faith


Long-Term Care Health Insurance Policy

Introduction

Coal mining can be dangerous work.  When a coal miner is in a serious accident, it can be catastrophic.  Tragically, some coal miners will need lifetime care by home health workers and nursing home care when they are in a serious coal mine accident.  Many coal miners plan for the risks of coal mining accidents by buying long-term care (LTC) insurance.  It has been one of the fastest-growing types of insurance sold in recent years.

In concept, LTC Insurance offers a coal miner a good solution to the problem of paying for assisted living or a nursing home if he or she should be catastrophically injured in a coal mining accident.   However, LTC Insurance is not always as straightforward as it sounds.  There are many potential pitfalls.

What is Long-Term Care Insurance?

The basic concept of long-term care insurance is simple.  A coal miner buys a policy and pays a premium to insure against the cost of assisted living or nursing home care should the time arise when the policyholder is no longer able to care for him or herself without assistance.  The difficult part is getting claims paid, which can be both frustrating and time consuming.  What’s more, a catastrophically-injured coal miner in need of these insurance benefits, who has paid premiums for years, too often does not have the strength or ability to fight with their insurance company, and are often cognitively impaired.  As a result, once benefits are denied, people give up and the insurance companies end up with all the premiums and no pay-out of benefits.  Some insurance companies may even count on this being the case. Insurance companies are in business to make money.  The more premiums that they accept, and the more claims they deny, the greater they will profit as a business.

Do Coal Miners Need Long-Term Care Insurance?

The main reason coal miners pay the high premiums for long-term care insurance is because the costs of paying for long-term care out of pocket can be even higher. Policyholders pay premiums to insure their financial and medical independence, but when a claim is denied, it can be financially devastating to both the injured coal miner requiring long-term care and also his or her family.

The most common conditions that may cause a person to need long-term care are:

  • Fractured bones commonly resulting from coal mining or other accident;
  • Recovery from an illness, injury or surgery;
  • Rehabilitation following a hospital stay;
  • Alzheimer’s disease and dementia;
  • Multiple Sclerosis (MS);
  • Parkinson’s disease;
  • Heart Disease;
  • Stroke;
  • Head injury (again, commonly caused by falls);
  • Chronic or terminal medical conditions.

There are many more illnesses and injuries that could cause a coal miner to need long-term care, but these are the most common.

 How Much Does Long-Term Care Insurance for a Coal Miner Cost?

The American Association for Long-Term Care Insurance says that a coal miner should expect to pay an average of $3,335 per year to cover a healthy 60-year-old couple on a plan that pays out a $150 daily benefit for up to three years.  Prices can vary dramatically, however, depending on factors such as the purchaser’s age, the level of inflation-adjustment protection and whether the daily benefit will be $100, or $150, or $200 per day.

 What Does Long-Term Care Insurance Cover?

Once the insured coal miner satisfies an elimination period, the type of benefit he or she will receive depends on the policy.  Most policies provide for either a daily or monthly benefit.

The daily or monthly benefit is the amount of money the insurance company will pay for each day or month that the insured coal miner qualifies for benefits under the policy.  Most policies reimburse for the costs incurred for covered services, but some policies also simply pay a pre-set cash amount for each day that the insured meets the “benefit trigger.”  If the cost of long-term care exceeds the maximum daily or monthly benefit, the excess is the responsibility of the insured.  How long benefits are available is determined by the maximum benefit period available under the policy.  An insured coal miner can opt to pay premiums for a shorter or longer benefit period, usually ranging from two to six years, or even through lifetime.

The types of coverage that a coal miner can purchase under a long-term care policy also vary. The insured can opt to pay for only nursing home care, which is sometimes referred to as a “facility care only” policy.  Or, the insured can opt to purchase coverage for a mixture of care options, including home care and other care, which is sometimes referred to as a “comprehensive” policy.

Some policies will even pay for a family member or friend of a coal miner to care for the insured in his or her home, and may also cover services or devices to support people living at home.  These might include: in-home equipment such as electronic monitoring systems; home modifications, such as grab bars and ramps; transportation to medical appointments; or even training for a friend or relative to learn to provide personal care safely and appropriately.

Thus, coverage will vary, based upon the policy provisions for which the insured coal miner chooses to pay premiums.  A person may also purchase additional options, sometimes call riders, to add more coverage under the policy. These may include a “non-forfeiture benefit” or “inflation protection.” Policies with the non-forfeiture benefit will provide that at least some benefits will be paid even if premium payments are not made and the policy is cancelled for non-payment of premiums.  Policies with the inflation protection benefit protect against the rising cost of care over time by the amount of insurance coverage increasing as the cost of long-term care increases. The bottom line is this:  each policy is different and what each policy covers varies.  The long-term care insurance policy covers what is agreed upon between the insured and the insurance company.

How Does a Coal Miner Make a Claim Under a Long-Term Care Insurance policy?

The terms of the long-term care policy govern any claim for benefits by a coal miner.  Thus, it is important for the policyholder/claimant to obtain a complete copy of the policy and understand what the insurance contract requires prior to filing a claim for benefits.  Next, the application for benefits is one of the most important documents in the filing of a claim.  The insured coal miner must keep in mind that the application is written by the insurance company and is geared to benefit the insurance company.  Thus, while the application may look like a simple form, it can often be worded to lead the insured toward certain types of answers or information and to discourage a full, accurate description of the situation.

As part of the application process, insurance companies may require an in-person or telephone interview with a claimant.

When Will My Benefits Start?

When benefits are paid depends upon the policy’s “benefit trigger,” the length of the elimination period that you choose and sometimes when you started receiving paid care. Most policies use Activities of Daily Living and Cognitive Impairment as triggers for benefits. The policy pays benefits when a coal miner needs help with two or more of the six Activities of Daily Living or you have a Cognitive Impairment.

The Activities of Daily Living usually include bathing, dressing, walking, moving from bed to chair, toilet, maintaining continence, and eating.  The Cognitive Impairment “trigger” is important in cases of Alzheimer’s disease or other illness affecting a person’s mental functioning.  Benefits will begin to be paid after you have satisfied your elimination period, if you qualify under the policy provisions.

The elimination period, which is the amount of time that must elapse after a benefit trigger occurs and before benefits will actually be paid, varies under long-term care policies, and can range from zero to a hundred days. You are not entitled to receive a benefit under your policy until you have satisfied the waiting or elimination period.

My Claim for Long-Term Care Insurance Benefits Has Been Denied.  Why?

Insurance companies interpret plan terms to advance their own financial interests and to deny or limit benefits.  They may engage in tactics such as denying receipt of necessary documents sent to them by the insured (“You faxed the medical information you sent from your doctor?  We did not receive it.  You will have to fax it again, but it goes to the back of the line for processing.”); using biased doctors and nurses to justify denial of claims (“Your claim is denied. The contract nurse we hired to perform a mini-psychological examination made findings contrary to the findings of your treating geriatric psychiatrist and his testing.  The nurse’s report says that you don’t have Alzheimer’s disease after all.  Congratulations!”); and even ignoring, or failing to advise an insured about benefits to which they are entitled.

Other examples of common claim delay or denial tactics utilized by insurance companies include the following:

Slow Walking

This is the practice of insurance companies delaying payment of insurance benefits by simply continuing to request additional, duplicative, and seemingly unnecessary information. The insurance company may claim that without this additional information, it is unable to approve your claim for benefits.  This can go on for months and even years if the insurance company is allowed to continue. In this situation, the insurance company is using a delay tactic to avoid paying the claim.  The hope is that many seriously injured coal miners/claimants will give up the fight against the insurance company because they are too disabled or sick, or even that claimants will die before benefits are paid.

Cancellation Due to Non-Payment of Premiums

Often when the need arises for someone to file for long-term care benefits, the insurance company will advise that premiums are outstanding and unpaid. Of course, many times the premiums are unpaid because the seriously injured coal miner insured suffers from a condition such as traumatic brain injury which affects his or her ability to remember to do things such as pay premiums.  Other times an insured will become too ill too quickly and will be unable to keep up with bills, or the insured is forced to choose between paying hospital bills instead of premiums.  There are requirements under a LTC policy and the law which require the insurance company to allow a certain period of time for an insured to become current with premium payments.  The insurance company may also be required to provide a “third-party designee” notice of non-payment of premiums before it is allowed to cancel the policy. However, if no one knows of these requirements, insurance companies are free to ignore or neglect to comply with these requirements.

Misconstruing a Limitation under the Policy and/or the Facts of the Claim

Insurance companies may rely on one or more of the following to deny the LTC claim of a coal miner:

  • The insured was not hospitalized prior to needing long-term care;
  • The insured does not suffer from an acute medical condition;
  • The long-term care services that were provided were not provided by a properly qualified professional or service provider as defined under the policy;
  • The long-term care services provided are available under Medicare or another governmental program;
  • The long-term care services that were provided are not covered under your policy;
  • The insured is able to perform “Activities of Daily Living”;
  • The care or services that the insured received are unrelated or unnecessary to carry out instrumental activities of daily living.
  • The care or services received are unrelated to the insured’s needs because of a cognitive impairment;
  • The insured did not need the level of care provided;
  • The insurance company’s doctor or nurse says that the insured does not qualify for long-term care benefits;
  • The insured has not provided sufficient ongoing verification of long-term care needs;
  • The insured suffers from a pre-existing condition;
  • The insured’s medical condition is not covered because it is the result of one of the following: mental illness, attempted suicide or intentionally inflicted injury, alcoholism or drug addiction, war or acts of war.

What do I do now?

Many wrongful denials of insurance benefit claims can be overturned without the cost, frustration and delay of filing a lawsuit, simply by supplying the right information and knowing how to respond to the insurance company’s accusations.  It is important to understand the common tactics used by the insurance companies to prepare an effective response. Before proceeding, it is also important to understand both rights and obligations under the insurance policy and the law that governs the claim.  State law governs private insurance policies.  Most group insurance policies, obtained as a product of employment, fall under the federal statute, ERISA. Both types of claims have unique and specific requirements for claimants in responding to their insurance company’s wrongful denial.

A Final Word:

Navigating the long-term care insurance claim process can be complicated and frustrating for many coal miners and their families.  Many times insurance companies will unfairly delay or deny the payment of benefits. This can be financially and emotionally devastating for seriously injured coal miners and families. With over 50 years of combined experience, our lawyers are in the business of making sure coal miners get the insurance benefits they paid for.  We anticipate the unfair and deceptive tactics employed by insurance companies to delay or deny the payment of long-term care benefits, and we are dedicated to leveling the playing field for coal miners.  We can use our experience in handling complex insurance benefit matters to guide our coal miner clients through the process and to vigorously fight to protect their rights.

The lawyers and staff at Underwood Law Office have the skills, experience and determination to fight for you to obtain benefits under your long-term care policy.  To discuss your needs in a free consultation, please contact the Underwood Law Office today.

 

 

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