Transamerica Long-Term Care Denial Lawyer

Has Transamerica Denied Your Long-Term Care Claim? Pillsbury & Coleman, LLP Can Help.

Long-term care (LTC) insurance is a vital financial safeguard, designed to protect your assets and ensure you receive the care you need as you age or face a chronic illness. Transamerica is a well-known provider of long-term care insurance, offering policies that aim to cover the significant costs of services like in-home care, assisted living facilities, and nursing homes. However, even with a Transamerica LTC policy, the process of securing benefits can be complex, and denials are an unfortunate reality for many policyholders.

At Pillsbury & Coleman, LLP, we understand the immense frustration and financial stress that a denied Transamerica long-term care claim can cause. After years of diligently paying premiums, you deserve the benefits you were promised. Our experienced long-term care denial attorneys are dedicated to helping Transamerica policyholders challenge unfair denials, navigate the often-confusing appeals process, and, when necessary, pursue litigation to secure the coverage you’ve earned.

When Should Your Transamerica Long-Term Care Claim Be Approved?

Transamerica LTC policies, like others, outline specific criteria for benefit eligibility. Typically, coverage is triggered when a policyholder is certified by a licensed healthcare practitioner as:

• Unable to perform at least two of six Activities of Daily Living (ADLs) without substantial assistance for an expected period of at least 90 days. These ADLs commonly include bathing, dressing, eating, toileting, transferring (moving in and out of a bed, chair, or wheelchair), and maintaining continence.
• Having a severe cognitive impairment that requires substantial supervision to protect them from threats to health and safety, such as with conditions like Alzheimer’s disease or dementia.

It’s also crucial to understand your policy’s “elimination period” – a waiting period before benefits begin to be paid. Transamerica policies may offer various elimination period options, including 0-day options for home health care, which can be a significant benefit. However, insurers may meticulously scrutinize your medical documentation and care plans against these criteria, sometimes using vague policy language to deny valid claims. This is where skilled legal intervention becomes essential.

Why Are Transamerica Long-Term Care Claims Denied?

Transamerica, like any large insurer, evaluates claims meticulously, and denials can arise from various factors. Common reasons for Transamerica long-term care insurance denials include:

• Insufficient Documentation: Transamerica may assert that medical records, physician statements, or care plans do not adequately demonstrate your eligibility for benefits according to their strict interpretation of policy terms.
• Disputes Over ADL Assistance: The insurer might argue that you can still perform certain daily activities independently, even if your condition clearly necessitates assistance. They may challenge the nature or level of “substantial assistance” required.
• Cognitive Impairment Challenges: Denials can occur if Transamerica deems a cognitive condition insufficiently severe, or if the policyholder’s participation in required cognitive testing is questioned.
• Policy Lapses: Missed premium payments, sometimes due to administrative errors, confusing billing, or even unaffordable rate increases, can lead to policies lapsing. While Transamerica aims for straightforward policies, such issues can still arise, especially for policyholders with cognitive decline who may struggle with managing finances.
• Non-Qualifying Care Providers or Facilities: Your policy may specify requirements for care providers or facilities. If care is received from unlicensed providers or facilities not meeting these standards, benefits could be denied.
• Pre-Existing Conditions: Transamerica may deny a claim by arguing the condition requiring care is a pre-existing condition not covered by the policy, even if the policy language is ambiguous or the condition was not properly disclosed.

These denials often stem from overly strict interpretations of policy language, procedural errors, or an insurer’s attempts to limit payouts. Our attorneys are adept at identifying and challenging such tactics through appeals and, if necessary, litigation.

How Pillsbury & Coleman, LLP Can Assist with Your Transamerica Long-Term Care Claim

At Pillsbury & Coleman, LLP, our long-term care denial lawyers have extensive experience challenging insurance companies, including Transamerica. We are committed to protecting your rights and securing the benefits you deserve. Our approach includes:

• Comprehensive Policy Review: We thoroughly analyze your Transamerica long-term care policy to understand your specific coverage entitlements, limitations, and the exact language the insurer is using to justify their denial.
• Evidence Gathering and Case Building: Our team works diligently to gather critical evidence, including updated medical records, independent medical evaluations, detailed physician statements, and care plans, to strengthen your claim and directly counter the insurer’s reasons for denial.
• Strategic Appeals: We craft compelling appeals that meticulously address each reason for denial cited by Transamerica, ensuring compliance with all policy terms and state regulations. We understand the specific appeal processes and deadlines for Transamerica claims. Our appeals attorneys can assist you every step of the way.
• Litigation Expertise: If an internal appeal is unsuccessful, we are fully prepared to escalate the matter through litigation. Our firm has a proven track record of pursuing insurance bad faith lawsuits, holding insurers accountable for wrongful denials and securing significant compensation for our clients. We fearlessly challenge major insurers to ensure your needs are met.
• Resolving Lapsed Policy Disputes: We investigate the circumstances surrounding any alleged policy lapse, examining whether proper notification procedures were followed or if the lapse resulted from insurer errors. We work to reinstate policies or recover benefits by proving bad faith practices, such as failing to notify secondary contacts.

Steps to Take After a Transamerica Long-Term Care Claim Denial

If your Transamerica long-term care claim has been denied, prompt action is crucial due to strict appeal deadlines. Here are essential steps to take:

1. Review the Denial Letter Carefully: Understand the specific reasons Transamerica provided for rejecting your claim and the policy provisions they cited.
2. Gather All Relevant Documentation: Collect your original policy, proof of premium payments, all medical records, care plans, and any correspondence exchanged with Transamerica.
3. Consult an Experienced Attorney: Engage a lawyer specializing in long-term care insurance denials as soon as possible. Their expertise can be invaluable in navigating the complex appeal process and building a strong case.
4. File a Timely Appeal: Work with your attorney to submit a comprehensive appeal that directly addresses each denial reason with clear, supporting evidence. Be mindful of all deadlines, which are often tight (typically 60-180 days).
5. Consider Further Legal Action: If your appeal is denied, your attorney can advise you on evaluating the possibility of filing a Transamerica lawsuit, as many denial practices have been successfully challenged in court.
6. File a Complaint with Your State’s Insurance Commissioner: This can trigger an investigation into Transamerica’s practices and provide additional leverage.

At Pillsbury & Coleman, LLP, we assist at every step, from evidence collection and crafting robust appeals to aggressive litigation. Don’t face Transamerica alone. Contact our Transamerica long-term care lawyer today at (415) 433-8000 for a free consultation to explore your options and fight for the long-term care benefits you’ve earned.