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Dec 30, 2016 by |

Our Alameda Attorney: Long Term Care Insurance and Denial of Benefits


Long Term Care Insurance Benefits Denied: What, Why, and How to Fix It

Background Knowledge of Long Term Care Insurance

Long term care insurance, in essence, is there to, unsurprisingly: take care of you long term. The basis behind the insurance is you purchase it, pay your premiums, and reap the benefits of the insurance in the later years of your life. By paying the base price and these premiums each month, you feel guaranteed to be taken care of if a situation were to arise in which you needed some in-home care, skill nursing care, or even the full-time care of a nursing home. However, in some cases, individuals can be denied from receiving the benefits of their insurance, even if they have paid every payment on time and enrolled in a hefty plan.

Why Benefits Can Be Denied

In light of this, it is important to understand how and why people are being turned away. One big issue is simple: coverage. In some policies, the insurers are very clear about what they will pay for and, consequentially, what they will not pay for. In these cases, individuals can pick a place to go, and they can be turned away by their long term care insurance company simply because their choice was not on the prescribed list. This is not necessarily a catastrophic problem, just one to be aware of when you are purchasing.
Another potential denying factor is whether or not the policy dictates that the insured must be hospitalized before entering into a long term care facility. It is noted that this type of guideline is mostly only in older policies, and it is being done away with around the country. Yet, if your policy was bought many years ago, that might be something to look into.
Policies can also sometimes be very particular in the language they use pertaining to caregiving. For example, some policies may not pay for care that is not medical, such as someone doing your grocery shopping or wiping down your kitchen counters. Not to mention, sometimes the policies delineate exactly who is to be considered a caregiver or simply a nice family member. Catch: they only pay a caregiver.
One final common aspect for denial of insurance coverage is missing payments. While that may seem obvious, sometimes the situation is difficult. For example, an individual may be getting older and becoming more forgetful, and they could forget to pay their insurance for a period of time. In that case, check in with your state codes and procedures, as some states mandate that insurance companies give a certain amount of “free” months in extenuating circumstances, meaning you could miss a number of payments and for good reason and your policy could still be alive or even reinstated if it had been terminated. Sometimes policies will have certain rules on it as well. This takes some research and light reading.

What To Do

Moral of the story: read your policy carefully. Understand which types of facilities are covered and which are not. Be sure to look into those types of places and decide whether or not you can see yourself being a good fit there down the road. If not, consider browsing around or even bumping up to the next level of insurance. Also educate yourself on late payments, paid care, and the fine details, like requiring a hospital stay before any long term care insurance kicks in. Being educated on your policy and the terms and conditions is critical. Do not be denied benefits when you need them because of something that could have been fixed earlier.

Contact Us

If you or a loved one has experienced any continuing care retirement community problems in California, contact the Evans Law Firm elder attorneys at (415) 441-8669, or by email at Our attorneys have experience with complex financial contracts and large insurance companies. We can help guide your case through a jury trial or toward an equitable settlement. We handle cases involving physical and financial elder abuse, qui tam and whistleblower law, nursing home abuse, whole life insurance and universal life insurance, and indexed, variable, and fixed annuities.

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