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Can Long-term Care Insurance Coverage Be Denied?

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Long-term care insurance can be a valuable tool. However, to get the most out of what you’re paying for, it is important to understand how your policy works. Each policy is different but most have similar components. Below, we look at some of the typical issues faced by long-term care insurance policy holders and what can be done if you’re denied coverage. 


Elimination Period


The “elimination period” on a long-term care insurance (LTC insurance) policy refers to the period between when the policyholder goes into long-term care and when the benefits begin to pay out. The length of this period can be 90 days or more. Ostensibly, the reasoning behind the elimination period is to ensure that the policy begins to pay when the policy owner is unquestionably in need of long-term care. The rationale is that the insurance company doesn’t want to pay if you go into a facility for a month and return home. Whatever the reasoning, many LTC insurance owners must pay a substantial amount of money for the first few months of care. This can come as a surprise for many policy owners and lead to financial hardship. 


Unintentional Policy Cancellation

What if the policy owner cancels or stops payment due to diminished capacity? Perhaps they are suffering from dementia and can no longer manage their affairs. Many policies include an exception to the cancellation that allow you to “reinstate” the policy if it was cancelled due to the diminished capacity of one or more of the policy owners. 
Typically, once the payments begin, the premiums for the policy are waived, meaning you do not need to pay premiums during the time in which a policy is paying out. However, the pay out can stop for many reasons. Perhaps the policy owner did not meet the policy’s definition of in need of coverage (more on this below) during recertification. Perhaps the insurance company wasn’t given the invoices for the care that they are paying for. Regardless, if the payments stop, the premiums once again become due. If the premiums aren’t paid, then the policy will be cancelled.


Prerequisites for Coverage


All LTC insurance policies have a prerequisite that must be met before they pay for care. Each policy defines this differently; however, it typically involves the policy owner needing substantial assistants with multiple activities of daily living (ADLs). 
Some of these definitions can be tricky and the insurance company will require proof that their definition is met before payment occurs. As such, there can be instances where someone is in need of care but can’t get the insurance company to pay because their medical record lacks a small ultimately insignificant detail. Because of the red tape and difficulty dealing with these insurance companies, it can be hard to determine what is missing.

What Can Be Done if Denied


All LTC policies have an avenue to appeal a denial of coverage. An appeal can be a difficult and lengthy process. The help of an attorney is crucial to navigate the appeal process. An attorney can assist with making the appeal, nailing down deadlines, and pinpointing what items of information are missing. An attorney can also help set the foundation for if the insurance company continues to deny coverage and the matter must be taken to court. 
If you have questions about how to handle Long-term Care Insurance Appeals, give the experienced attorneys at McIntyre Elder Law a call at 888.999.6600. 

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Brenton S. Begley

Elder Law Attorney

McIntyre Elder Law

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