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Long-Term Care Insurance Denials of Benefits for Nursing Home or Assisted Living Facilities

Private health insurers and Medicare pay for nursing home care or assisted living only under limited circumstances, such as when skilled medical care or rehabilitative services are required after a hospital discharge. No coverage is provided for custodial care, which is the type of care most seniors need when going into a nursing home. If a senior only needs assistance with routine activities and does not require specific medical assistance, such as changing sterile bandages, nursing home costs for this senior would not be paid by virtually any health insurer, with the limited exception of Medicaid for seniors with few assets.

Long-term care policies are purchased by those who wish to be financially responsible by ensuring nursing home care can be paid for. Some of the companies that provide such coverage include Genworth, Metlife, Conseco, UNUM, AEGON, Prudential and John Hancock. Policyholders with long-term care coverage pay hundreds or thousands of dollars in premiums for the peace of mind of knowing an insurer will pay in case nursing home admission becomes necessary.  Unfortunately, it is common for insurers not to pay.

When benefits for nursing home or assisted living care are denied after paying long-term care insurance premiums, you are encouraged to speak with San Mateo County elder abuse lawyers as soon as possible.

Some of the Tactics Used to Deny Nursing Home & Assisted Living Coverage Under Long-Term Care Policies

Insurance companies try numerous tactics to deny claims that should be covered under long-term care policies.  Most long-term care policies provide coverage for nursing home care only if one or more of three requirements is met:

  • The policyholder is cognitively impaired. Dementia or other cognitive problems have made it necessary for the policyholder to have continued supervision. Clinical evidence and standardized tests can provide evidence of impairment.
  • The policyholder has experienced a loss of functional capacity. The key question here is whether the policyholder is able to do routine activities of daily living such as using the bathroom; showering; eating; getting dressed; or moving- including moving into a wheel chair. A policy may require an inability to do routine daily living activities before a patient’s claim for nursing home admission will be granted.
  • Admission to a nursing home or assisted living facility is medically necessary. The patient has some type of medical condition which cannot be managed at home and which necessitates specialized care provided by medical professionals.

Long-term care insurers may claim insufficient proof in nursing home records and assessments to demonstrate that one of these criteria have been met. Long-term care insurers may also unreasonably deny claims without providing justification; may require applicants to provide an unreasonable amount of documentation; or may deny claims based on unreasonable interpretations of policy language.

Whatever the reason, a denial of a claim for long-term care benefits can be a devastating blow to someone who thought he had done the right thing and bought coverage but who ultimately learns that the policy won’t pay when needed. A financial elder abuse lawyer can provide help to seniors who have long-term care coverage and whose claims for nursing home care or assisted living care have been denied. Find out how to take action against insurers who fail to provide promised coverage. The Evans Law Firm, Inc. is prepared to help you. Call us at 415-441-8669 or toll free at 888-503-8267.

Source: AARP – http://www.aarp.org/health/health-insurance/info-06-2012/understanding-long-term-care-insurance.html

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