Why are long-term care benefits denied?

On Behalf of | Sep 3, 2019 | Estate Planning

As a Washington resident, it is possible that an insurer may deny your long-term care insurance claim. Even though you may have spent years paying premiums, it helps to know a few reasons for such denials. Having this information may help you avoid a claim denial.

According to Forbes, long-term care policies in the 1990s were quite different from what they are now. At that time, the long-term care industry was emerging and not well-regulated. Additionally, the policies were not written with long-term, assisted living care in mind. The primary focus was on home healthcare and nursing home coverage. Unprepared insurers did not have the ability to handle the financial cost of claims associated with assisted living. This resulted in many claim denials.

Even though current policies are more comprehensive, you may still run into problems with getting your claim paid, for several reasons:

  • A long-term care facility may not meet the insurance provider’s criteria, such as having a specific license.
  • You have not had a prior hospital and/or nursing homestay.
  • Your policy does not provide coverage benefits if a family member or in-law cares for you.
  • If you miss premium payments the carrier may cancel your policy.

There are key factors worth considering if you face any of these issues. For instance, many states have outlawed the “gatekeeper provision” requiring a previous hospitalization and/or nursing homestay. This was most common with older long-term care policies.

With denials based on family members and in-laws caring for you, it is always a good idea to read the wording in your policy. Sometimes the language is vague as it relates to this particular circumstance.

Did you fail to pay your premiums due to cognitive impairment? Was your policy canceled as a result? If so, many states grant policyholders a five-month window of nonpayment before a policy lapses. An insurer may reinstate the policy if you have a doctor’s statement explaining you suffered from cognitive impairment during the time you missed your payments.

This information provided is for educational purposes, and it is not legal advice.