Why Was My Long-Term Care Insurance Claim Denied?

You invested in long-term care insurance as part of your life planning. You’ve paid the steep premiums. When it works correctly, LTC insurance can provide important financial assistance when you cannot care for yourself. But all too often, you may find that when you need the benefits, the insurer refuses to pay them.

At Jonathan M. Feigenbaum, Esquire, we guide individuals and families through their emotionally-charged and complicated LTC claims. If you had your long-term care insurance claim denied, we can help.

Why Do Companies Deny Long-Term Care Insurance Claims?

The vast majority of long-term care insurance companies are for-profit businesses. That means that they are more focused on their financial bottom line and shareholders than the best interests of the seriously ill or disabled individuals who file claims.

Compared to many insurance claims, long-term care is incredibly expensive — a private room in a nursing home or long-term care facility can cost more than $83,000 per year. In other words, there are incentives for insurance companies and their adjusters to carefully scrutinize these claims and look for reasons to deny them.

Reasons Why Your Long-Term Care Insurance Claim Was Denied or Delayed

Below, we outline some of the most common issues that arise during a long-term care claim. It’s important to remember, however, that there are many reasons why you may have your long-term care insurance claim denied. To truly understand your case, it is best to consult with an experienced LTC lawyer who can provide a personalized analysis and suggest practical next steps.

Alleged Nonpayment of Long-Term Care Premiums

Sometimes, people miss or make a late payment. In these situations, the insurance company may argue that your policy lapsed and you are no longer eligible for benefits. However, there are strict rules about how insurance companies must behave when there’s a missed a payment. If they do not follow these required steps, you may still be eligible for long-term care benefits.

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.

You Can Perform Some Limited Activities of Daily Living

Most long-term care policies require that you cannot perform activities of daily living, such as making food, eating, dressing, walking, and using the toilet, before you are eligible for benefits. Sometimes, people have limited abilities to perform these tasks, but it is still not safe for them to live independently. In these cases, the insurance adjuster may improperly deny their long-term care claim.

Conflicting Medical Opinions

The insurance company may send your information to a reviewing physician. This doctor will not examine you — instead, they will simply read your records and provide an opinion about your eligibility for benefits. Many times, the insurance company will follow their paid consultant’s opinion over your physician’s statement that supports your claim.

Your Condition Improved and You No Longer Qualify

Sometimes, with consistent care, people stabilize or even improve. However, that does not mean that they can live independently. However, the insurance company may use this incremental improvement as an excuse to terminate your long-term care benefits.

Your Medical Condition Is Excluded

Many long-term care policies include exclusions that deny care if you have a pre-existing condition, your injuries were self-inflicted, or related to substance use. An experienced long-term care lawyer can help you evaluate your insurance policy and determine whether you actually fall into an exclusion.

If You Had Your Long-Term Care Insurance Claim Denied, Speak to an LTC Attorney

Long-term care claims require a careful analysis and sophisticated legal strategy. Rather than struggle through your claim alone, consult with an experienced attorney at Jonathan M. Feigenbaum, Esquire. We know the tactics LTC insurance companies use to delay or deny claims, and we may be able to help. To request an appointment, contact our office today for a complimentary evaluation of your claim and guidance on the next steps you need to take.