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Long-Term Care Denial: How to Help a Loved One in Need

April 17, 2023

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Home » Blog » Long-Term Care Denial: How to Help a Loved One in Need

We Fight Insurance Companies So You Don’t Have To

Aging is one thing we cannot escape, and a person’s health and care needs can shift quickly over time and often without warning. People with serious or ongoing health conditions, illnesses, or disabilities that happen gradually or unexpectedly might need long-term care to manage basic needs and daily living at home, in a nursing home, or another facility.

Long-term care insurance is a big decision, and popular industry players like CNA and Lincoln Benefit are usually the top-of-mind choice. We want the best for ourselves and our loved ones, but these companies, unfortunately, often exploit customers more than they help them by unfairly denying or rejecting long-term care claims.

Unreasonable long-term care insurance denials can feel like a personal and financial attack on you and your family. Seasoned health insurance dispute attorneys at Wallace Law ensure you or your loved ones always have an advocate against unfair insurance practices.

What is Long-Term Care Insurance?

Long-term care insurance ensures a person with an extended illness, such as Alzheimer’s, cancer, or diabetes, can get reimbursed for assistance with basic needs like bathing and dressing.

Long-term care is offered to people, usually 60 years or older, in settings like nursing homes, adult day care centers, group living facilities, or at home. The need for long-term care insurance increases with age, but anyone with prolonged health issues can use it.

Long-term care insurance is only an option for some. Many people do not know they can pay for long-term care expenses with a policy they already have: life insurance. A long-term care rider changes how a life insurance policy works, allowing you to use some or all of your death benefit to receive long-term care support when needed. To qualify, a medical professional must confirm the policyholder cannot perform at least two activities related to daily living.

What is the Difference Between Long-Term Care Insurance and Accelerated Death Benefit Riders?

Long-term care insurance covers care costs after a person experiences a lengthy illness, health disorder, or disability. It is most common for people over 70 to file long-term care claims.

Accelerated death benefit riders, on the other hand, help people who are chronically or terminally ill exclusively. These are add-ons to a life insurance policy, allowing a policyholder to use a portion to cover health-related costs while still alive.

There are two accelerated death benefits: long-term care, and chronic and critical illness riders. Long-term riders allow people to use some or all of their policy’s financial benefits. In contrast, policyholders with chronic and critical illness riders can use their policy’s benefits based on qualifying health issues.

two senior citizens sitting in an office, looking upset

Eligibility for Long-term Care Insurance Benefits

Long-term care insurance benefits “kick in” when a person meets specific criteria of their long-term care insurance policy. When a health condition or disability hinders a person from fulfilling basic activities, such as bathing, dressing, and eating, this is one way they become eligible for long-term care assistance.

The second way a person qualifies for long-term care insurance benefits is if they suffer from cognitive impairment. This might include memory issues, lack of reasoning, thinking, or awareness and recognition. Familiar examples of cognitive impairment include Dementia or Alzheimer’s disease. A person might be ready for long-term care support if they risk harming themselves.

Helping a loved one through serious health and lifestyle changes can be a vulnerable time for everyone involved. Wallace Law is a resource for families when long-term insurance issues arise, like denied health insurance claims.

Reasons for Delay or Denial of Long-Term Care Insurance Coverage

Insurers must fulfill their contractual obligations. If you or your loved ones meet the requirements of long-term care insurance coverage, bills are paid on time, and benefits have not been exceeded, the insurance company should have no valid reason to deny or delay your claim.

However, this only sometimes happens as there are always reasons long-term care claims get approved or denied. Some examples of when long-term care benefits may be denied include:

  • Insurance barriers in contracts often include gatekeeper provisions created by insurance companies to set a higher threshold for the “chronically ill” standard a person must fall under to get coverage. This essentially makes it more challenging for policyholders to get access to coverage.
  • Medical reasons like conflicting medical opinions, requests for second or third opinions, additional reviews of a person’s health records, or denying a payout after conditions have improved can make it substantially easier for a policyholder’s claim to get denied.
  • Lack of coverage for personal care services can cause serious financial complications for a chronically or seriously ill person and result in denied benefits.
  • Delaying payments using harmful tactics like demanding more paperwork, disputing policy terms and conditions, or creating strict standards for qualified nursing homes can stall the process.
  • A prior confinement provision will require that a policyholder must have had prior hospitalization confinement or a nursing home stay for benefits to be paid.
  • Insufficient documentation, errors, or inaccurate information can hinder getting approval.
  • Lapses in premium payments can disrupt the insurance plan and impact coverage later.

Not all insurance companies deny or reject claims intentionally, but it is important to pursue any questionable actions. When in doubt, Wallace Law can review your long-term care insurance claim to determine if you have a case against your insurer.

Long-term Care Insurance Denied: What Should I Do?

A denied or delayed long-term care insurance claim can take a serious financial toll on your family. You might not know where to turn or what to expect. So what can you do when your long-term care insurance claim is denied?

The following steps are a great place to start:

  • Identify why your claim was denied, starting with your insurer. Re-review your policy and cross-reference it with the insurance company’s denial letter to identify errors.
  • Gather all documents and evidence, including any communication with the insurance company.
  • File an appeal and submit all appropriate documentation and paperwork to get the process moving swiftly.
  • Contact a long-term care insurance dispute lawyer to discuss potential legal proceedings following an ineffective appeals process or after all other methods have failed.

How to Appeal a Long-term Care Insurance Denial

You might consider an appeal if your long-term care claim has been denied. The first step is to learn the basis for the denial so that you can request an appeal with facts to support it.

The appeal process will call for pertinent details like medical records, physician statements or notes, and other basics, like policy or case number and contact information.

A successful appeal is based on how closely you follow your insurance company’s procedures, including a proper submission with accurate and detailed information regarding the claim.

Do I Need A Long-Term Care Denial Attorney?

The long-term insurance claims process can feel like you are jumping through many hoops to reach a resolution. Long-term care insurance contracts are complex, regulations are tough to follow, and other factors can complicate the claim denial process.

Fortunately, a skilled insurance dispute attorney can save you time and likely money when you cannot reach a mutual agreement with your insurance company.

Wallace Law and our insurance dispute legal services can ease the burden by helping you file an appeal and representing your rights in litigation should the case against your insurer go to court.

Long-Term Care Denial: FAQs

How much does long-term care insurance cost?

Long-term care insurance costs depend on age, health, and overall condition. On average, a 55-year-old man will likely pay a $2,200 annual premium, while it costs a woman the same age approximately $3,700 annually. Long-term care insurance premiums increase by 45 percent if enrollment happens after age 60.

What is the difference between long-term care insurance and an accelerated death benefits rider?

Long-term care insurance allows people with prolonged illnesses to get reimbursed for assistance with daily living activities, such as bathing, dressing, and taking medication. Chronically or terminally ill people can use a life insurance policy add-on known as an accelerated death benefits rider to pay for immediate health care needs.

What is the accelerated death benefit for chronic illness riders?

A person diagnosed with a serious chronic or critical illness, such as a heart attack or stroke, can access funds to pay for care using a chronic illness rider. A chronic illness rider is a type of accelerated death benefit which allows a person to tap into their life insurance policy to access funds for care if they qualify for certain chronic illnesses. A person can use anywhere from 25 to 100 percent of the funds to pay for important services like an at-home nurse.

What are activities of daily living?

When a person can no longer function independently due to an illness, injury, or health condition, it impacts their ability to complete basic, daily living activities. Core activities of daily living include:

  • Eating and feeding oneself
  • Maintaining routine hygiene, like bathing and showering, and brushing their teeth
  • Getting dressed and undressed
  • Sitting, standing, or walking
  • Controlling bowel and bladder function
  • Getting to and from the toilet, as well as cleaning oneself

What is the average cost of nursing home care?

There are many nursing homes, assisted living, and independent living facilities to choose from at different price points and with a variety of amenities.

In Wisconsin, for example, the average nursing home care cost is approximately $9,022 monthly for a semi-private room and nearly $9,733 for a private room.

What is the statute of limitations for fighting a denied long-term care claim?

The statute of limitations for filing a lawsuit to fight a denied long-term care claim varies state to state. In Wisconsin, a person has one year from the date of the policy inception to fight a denied long-term care insurance claim. If you have questions about the claims process or how to proceed, insurance dispute attorneys with Wallace Law are well-equipped to advise you.

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Talk to a Long-term Care Insurance Denial Lawyer

There is no shortage of pitfalls in long-term care insurance, especially involving big insurers like CNA or Lincoln Benefit. They might stall or deny your long-term care plans to make a quick profit. Fortunately, bad faith insurance practices and insurance companies with big legal teams are no match for Wallace Law.

Our firm is built on protecting policyholder rights, and we are an aggressive legal resource when you lose hope and grow tired of fighting. We can help you through the claim denial and appeals process and represent you in litigation when other resolution methods fail.

Contact us today for a free legal consultation to see how we can assist with your long-term care insurance claim.



Do long-term care insurance policies cover pre-existing conditions?

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Do I need to be hospitalized to be eligible for long-term care?

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Do I still qualify for long-term care benefits if my health conditions improve but I am still unable to live independently?

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What should I do if I cannot afford a long-term care denial attorney?

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