Long-term care insurance claims are denied for various reasons, many of which may be improper or challengeable. Common reasons include insurers claiming you don't meet the policy's benefit triggers (such as being unable to perform two or more Activities of Daily Living), asserting that the care you're receiving isn't "medically necessary," or arguing that your condition is excluded under the policy. Insurers may also deny claims due to alleged misrepresentations on your original application—even for minor omissions made decades ago. Some denials are based on incomplete medical documentation or the insurer's selective interpretation of policy language. At the Law Offices of Sean K. Collins, we thoroughly review denial letters, analyze your policy terms, and identify where insurers may be acting in bad faith or misinterpreting their obligations to policyholders.

Activities of Daily Living (ADLs) are basic self-care tasks that most long-term care insurance policies use as triggers for benefit eligibility. The six standard ADLs are: bathing, dressing, toileting, transferring (moving from bed to chair), continence, and eating. Most LTC policies require that you be unable to perform two or more ADLs without substantial assistance, or that you have a severe cognitive impairment, to qualify for benefits. Insurers often dispute whether you truly need help with these activities or whether the assistance you're receiving counts as "substantial." They may rely on their own assessors who spend minimal time evaluating you, rather than the detailed assessments from your treating physicians and caregivers. We help policyholders gather the right medical evidence and challenge insurer assessments that minimize your care needs.

Yes, unfortunately, long-term care insurers can and frequently do raise premiums, even on policies you've held for decades. Unlike some other insurance products, most LTC policies are not guaranteed renewable at the same premium. Insurers must obtain state regulatory approval for rate increases, but these approvals are often granted. Some companies have implemented premium increases of 50%, 100%, or even more, forcing policyholders to either pay substantially more or reduce their benefits. While individual rate increases are generally legal when properly approved, there are situations where insurers have engaged in improper practices—such as using flawed assumptions, discriminating against certain policyholders, or implementing increases in ways that violate state regulations. Our firm is currently involved in class action litigation examining insurer practices related to premium increases. If you've faced significant rate hikes, we encourage you to contact us to discuss whether you may be part of a class action or have individual claims.

The elimination period (also called the waiting period or deductible period) is the number of days you must receive and pay for long-term care services before your insurance benefits begin. Common elimination periods are 30, 60, 90, or 100 days. During this period, you're responsible for all care costs out-of-pocket. Importantly, not all days may count toward your elimination period—many policies only count days when you're actually receiving care that would otherwise be covered. Insurers sometimes dispute which days count, particularly if care was intermittent or provided by family members. Understanding how your elimination period works and ensuring the insurer properly credits your waiting days is crucial. We help policyholders navigate these calculations and challenge improper extensions of elimination periods.

This depends entirely on your specific policy. Older LTC policies often covered only nursing home care, while more modern comprehensive policies typically cover home care, assisted living, adult day care, and nursing home care. However, even when home care is covered, insurers may impose restrictions such as requiring care providers to be licensed or certified, limiting which types of home modifications are covered, or requiring prior authorization. Some policies have different daily or monthly benefit amounts for home care versus facility care. It's critical to understand your policy's specific coverage provisions. Many claim denials occur because policyholders or their families misunderstand what types of care are covered or fail to follow required procedures. We analyze policies to determine exactly what coverage you're entitled to and hold insurers accountable when they improperly restrict home care benefits.

Insurance companies often overwhelm policyholders with documentation requests as a strategy to delay paying claims or to discover grounds for denial. While insurers are entitled to reasonable documentation to verify your claim—such as medical records, care plans, and proof of services received—excessive or repetitive requests may constitute bad faith. If your insurer is asking for the same information multiple times, requesting irrelevant medical history, imposing unreasonable deadlines, or creating bureaucratic obstacles, you may need legal assistance. We help policyholders respond appropriately to documentation requests while protecting your rights and pushing back against insurer tactics designed to frustrate valid claims.

Absolutely. If your LTC claim has been denied, you have the right to appeal, and you should act quickly as appeal deadlines vary by policy and state law. The appeals process typically involves multiple levels: an internal appeal with the insurance company, and potentially an external independent review depending on your state's regulations. A successful appeal requires presenting compelling medical evidence, detailed care documentation, a thorough legal analysis of your policy terms, and often expert opinions supporting your need for care. Many policyholders who attempt to appeal on their own are unsuccessful because they don't know how to effectively challenge the insurer's reasoning or don't present the evidence in the most persuasive way. Our firm has extensive experience navigating LTC insurance appeals and significantly improving policyholders' chances of overturning wrongful denials.