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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
  • AEGON
  • 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.

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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