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Denial of Claims for Continuing Care Residential Facilities

Nursing homes may cost an average of $83,950 a year for a private room; so many people purchase long-term care insurance or coverage in case they or a family member needs to go into a nursing home or skilled nursing facility.

You may assume you are safe from financial loss when a policy is purchased, but sadly, this is not a reality. Denials of claims are very common, and many people face extreme financial hardship due to a claim denial for skilled nursing care or assisted living. You or your family member needs to be able to get bills paid right away when it becomes necessary to enter a skilled nursing home or long-term care environment, so you should consult with a California financial elder abuse attorney for help as soon as possible if your claim is denied.

Denial of Claims for Skilled Nursing Facilities

There are many different providers of long-term care insurance, including:

  • Genworth
  • Metlife
  • Conseco
  • UNUM
  • Prudential
  • John Hancock

These insurance providers and other long-term care insurance companies paid out more than $7.5 billion in insurance claims to 273,000 Americans in 2013. Unfortunately, while there are some good providers in the business, there are also some problems in the long-term care insurance market. In particular, in the 1990s, the market was not very heavily regulated, so people with older policies who have been paying premiums for a long time may have the hardest time getting covered.

Still, with all types of policies, it is possible insurers will find excuses to deny coverage. For example, some common reasons insurers refuse to pay claims as promised for skilled nursing home care or assisted living care include:

  • Disputes over whether the senior is able to complete activities of daily living
  • Claims that a particular facility is ineligible
  • Assertions that the policyholder should not be covered because there was no hospitalization prior to nursing home admission
  • Claims that policies do not provide coverage for personal care like errands run by caregivers for policyholders

In other situations, seniors face problems because they begin to experience cognitive impairments as they age. A senior suffering from dementia could accidentally forget to pay the policy premiums because of cognitive impairment, which could result in the policy lapsing just when the coverage is needed the most. When this occurs, it may sometimes be possible to get coverage reinstated by providing a doctor’s note showing that the premiums were not paid as a result of a condition affecting cognitive function.

Denial of Claims for Continuing Care Residential Facilities 


Genworth Financial, founded in 1871, provides a variety of long-term care funding and service products. One of its hallmark features is its aging simulator, which allows users to test how their vision, hearing, and mobility will change as they age. 


MetLife, founded in 1868, is a global behemoth in the insurance, annuities, and employee benefits industries. While Metlife is generally considered financially strong, it has received more customer complaints than other companies of its size. 

CNO Financial Group

CNO Financial Group, formerly known as Conseco began its operations in 1982. In addition to long-term care insurance, it also offers short-term care and home care insurance. 

Mutual of Omaha

Mutual of Omaha was founded in 1909. Its long-term care policies are highly customizable, offering benefits like inflation protection, shared care with a partner, and premium reimbursements. 


Nationwide was founded in 1926, making it the youngest insurance provider on this list. Its long-term care insurance benefits can also be paid to family caregivers, and it provides guaranteed death benefits to policyholders. 

New York Life

New York Life was founded in 1845. One of its most innovative products is its combination of life insurance and long-term care insurance policy. 

John Hancock 

John Hancock Financial was founded in 1862. It offers an interactive tool to help prospective policyholders determine how much long-term care insurance they will need. 

What to Consider Before Purchasing Long-Term Care Insurance 

When planning for elder care, keep the following considerations in mind when selecting a long-term care insurance policy: 

Duration of Benefits

Long-term care insurance does not last forever. Most companies offer policies that pay for care in one-, two-, three-, or five-year increments. Generally, the longer the benefits last, the more expensive the policy will be. 

Waiting Periods 

A long-term care insurance waiting period is the amount of time an insured must wait after becoming eligible for benefits to receive those benefits. Many long-term care insurance policies have 30-, 60, or 90-day waiting periods during which the insured must pay for their care out of pocket before benefits kick in. In lieu of a waiting period, other policies have deductibles that must be met before a benefits trigger. 

Benefit Triggers 

A benefit trigger is a condition that must be met before a long-term insurance policy will begin paying benefits. Benefits typically are triggered when the insured is no longer able to provide for their own activities of daily living, such as eating, bathing, or dressing, or when the insured receives a diagnosis of a cognitive impairment (such as dementia). 

Daily Benefit Amounts

Most long-term insurance plans pay a set amount for each type of care. For example, a policy may pay $100 per day for care in a nursing home, but only $70 per day for assisted living

Inflation Protection

The cost of long-term care rises every year. To guard against inflation, many policies offer optional inflation protection, which steadily increases a policy’s benefits by a certain amount. While inflation projection can provide some cushion against the increasing cost of care, it typically results in higher premiums.  

Contact a California Financial Elder Abuse Attorney Today 

Regardless of the reason for denial of claims for skilled nursing facility coverage, policyholders and their family members should get legal help if they have paid premiums and an insurer is refusing coverage in their time of need. A financial elder abuse attorney in California can carefully review your policy and your personal situation and help you determine what your options are for making a claim against an insurer for denial of claims for skilled nursing care or admission to a nursing home. Contact the Evans Law Firm, Inc. today. We can be reached by phone at 415-441-8669 or toll free at 888-503-8267.

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