The Long Island newspaper, Newsday, in an article published March 9, 2023, reported that “Long-term Care Insurance can be Complicated Answer for Long Island Seniors.” The article discusses the challenges faced by long term care insurance policyholders as they try to file claims for benefits under their policies. Mark Scherzer was cited in the article as an attorney “who has helped families whose long-term care claims have been rejected.”
People submitting long term care claims are often puzzled why the insurance company says that a letter from a doctor — recommending assistance at home, residence at an assisted living facility, or treatment at a skilled nursing facility — is not enough evidence to pay the claim. Why isn’t the claim approved based on a statement that the individual has been diagnosed with Alzheimer’s disease or is having trouble accomplishing their activities of daily living? Some policies require proof of the need for care through standardized testing or other “objective” measures. Mr. Scherzer noted in the article that it can be very important to submit copies of medical records and results of testing that the doctors perform. Further, it may be necessary to go beyond just the test results themselves. He cited an example where the long term care insurer denied a claim because the policyholder’s cognitive function on a mental status examination fell within normal limits. Mr. Scherzer was able to reverse the denial after showing not only that the policyholder’s cognitive functioning had — in fact — declined over time, but also, based on medical literature, that what may be “normal” cognitive function for the population on average may be sub-normal when the individual is highly intelligent and educated. Detailed attention to each person’s situation and difficulties, with support from doctors, family members and caregivers may be essential.
If you’re having difficulties filing a long term care claim, or have received a long term care claim denial, our attorneys can provide legal assistance with your long term care claim in a number of ways.
Mark Scherzer is a New York-based long term care, health insurance, and long term disability claim lawyer with over 40 years’ experience handling claims arising under both individually purchased and employer-sponsored health and long term care insurance.