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 or not having a severe enough Cognitive Impairment), or arguing that your provider (often an independent home health aide or an Assisted Living Facility) is excluded under the policy. 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’s 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 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.

It depends on your policy language and how the insurer applied the rate increases. While the long-term care insurance would answer this question with a “yes” it is not that simple. There are a lot of factors that need to be considered when assessing the propriety of a rate increase. 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 0, 30, 60, 90, or 100 days. During this period, typically you're responsible for all care costs out-of-pocket, but it all depends on your specific policy language. 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 facility based care, while more modern comprehensive policies typically cover home care, skilled nursing facilities, assisted living and adult day care. However, even when home care is covered, insurers may try to impose restrictions such as requiring care providers to be licensed or certified a particular way, even when your state requires no such licensing/certification. 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. While insurers are typically 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 - but thoroughly - as appeal deadlines vary by policy and state law. 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.

The timeline varies considerably depending on the complexity of your case and the insurer's responsiveness. Some disputes can be resolved through negotiation or the internal appeals process within a few weeks. Others, particularly those involving bad faith practices or requiring litigation, may take several months, or even years if litigation is necessary. Throughout the process, we work diligently to move your case forward as quickly as possible while ensuring we build the strongest possible claim.

Bad faith occurs when an insurance company fails to deal fairly and honestly with policyholders or unreasonably denies or delays legitimate claims. Examples of bad faith in the LTC insurance context include: denying claims without reasonable investigation, relying on biased assessors while ignoring treating physicians, imposing arbitrary deadlines or documentation requirements, misrepresenting policy terms, or failing to properly explain denial reasons. When insurers act in bad faith, policyholders may be entitled to damages beyond the policy benefits, including compensation for emotional distress, attorney fees, and in some cases, punitive damages. Proving bad faith requires demonstrating that the insurer didn't just make a mistake, but acted unreasonably or with improper motives. Our firm can help identify whether bad faith is an issue in your case, and if so, work to prove that the bad faith conduct infected the insurer’s claim process.

Many insurance dispute cases, including long-term care insurance claims, are handled on a contingency fee basis, meaning you don't pay attorney fees unless we recover benefits for you. Some clients however choose to hire us on a flat fee or hourly basis. During your initial free consultation, we'll discuss the fee structure that applies best to your specific situation. Our goal is to make quality legal representation accessible to policyholders who are already facing financial stress from denied or delayed insurance benefits. We're transparent about costs from the outset so you can make an informed decision about representation.