Reasons Long-Term Care Benefits Are Delayed or Denied

Proper Licensure of Facility
If you, a friend or loved in a nursing home or an assisted living facility, the operator must prove to the Long-Term care insurer that it’s an “eligible care provider.”

No Prior Hospitalization
This is sometimes known as “the gatekeeper provision” and often appears in older Long-Term care policies. This wording requires that a policyholder had hospitalization confinement, a nursing home stay, or both before claims would be paid.

No Benefits for Personal Care
Some insurers may say they won’t pay benefits for “personal” care, such as light housekeeping or errands a caregiver must run for the policyholder.

Failure to Pay Claims Due to Cognitive Impairment
Sometimes, benefits are denied because the policyholder forgot to pay the premiums due to the insurance company because the policyholder is cognitively impaired. But in most states, you have up to five months before a policy can lapse because premiums weren’t paid. If you can get a physician’s statement demonstrating your parent or loved one is cognitively impaired during a particular time, the insurer may reinstate the policy.