Common Claim Delay or Denial Tactics Employed by the Insurance Company

Insurance companies spend a great deal of time and money training their claims examiners and investigators to highly scrutinize every claim filed. Insurance companies often take advantage of unrepresented claimants by employing unfair tactics to delay and deny claims. They also employ in-house and local attorneys to vigorously defend and litigate insurance cases. Without legal representation, your ability to overcome such resources may be limited. Contact Di Law Group to discuss your legal needs in a free consultation.

Slow Walking

Insurance companies regularly delay payment of insurance benefits by simply continuing to request additional, duplicative and seemingly unnecessary information and documentation. The insurance company will assert that without this additional information, it is unable to approve your claim for insurance benefits. This can go on for months and even years if the insurance company is allowed by you to continue.

The sad truth is the insurance company is employing a delay tactic called slow walking to avoid paying the claim. Even sadder is that many claimants may give up the fight against the insurance company that outnumbers them in resources because they are too disabled or sick, or they may even die before benefits are paid. Don’t give up your claim. Contact us for a free consultation to find out how one of our attorneys can help you appeal this delayed claim.

Lapse of Policy Due to Nonpayment of Premiums

When the need arises for you to file for your long-term care benefits, or your loved one’s benefits, you may suddenly learn that premiums are outstanding and unpaid. What insurance companies refuse to acknowledge is that many times the premiums are unpaid because the insured suffers from a condition such as Alzheimer’s or dementia that affects his or her ability to remember to do things such as pay premiums, the insured became too ill too quickly and was unable to keep up with bills or the insured was forced to pay hospital bills instead of premiums.

Because of these common reasons for nonpayment of premiums, there may be requirements under your policy and the law that require that the insurance company give the insured a certain period of time to become current with premium payments, and also require that a “third-party designee” be notified of missed premium payments. Our attorneys aggressively assert your rights to have your policy reinstated and benefits paid in these circumstances, even when the deadlines may have passed under the law or your policy for reinstatement.

Denial Because of a Limitation Under Your Policy

Common denial tactics used by insurance companies in long-term care claims include the following:

• You weren’t hospitalized prior to needing long-term care, and thus the insurance company has denied your claim
• Because you do not suffer from an acute medical condition, your benefits have been denied
• The long-term care services that were provided to you were not provided by a registered nurse, licensed practical nurse or other properly qualified professional as defined under your policy, and the insurance company has denied benefits for these services
• The care or services were provided to you by a family member and the insurance company asserts that these are not covered
• The long-term care services that were provided to you were not provided by a nursing home or home care provider that is certified by Medicare
• The insurance company is alleging that the long-term care services provided for you are available under Medicare or another governmental program, and thus denying your benefits arguing that these services are not covered
• The long-term care services that were provided to you are not covered “skilled care,” and the insurance company is refusing to pay
• The insurance company is asserting that you are able to perform your “activities of daily living” and are refusing to pay for your long-term care claim(s)
• The insurance company claims that the care or services that you received are unrelated or unnecessary for you to carry out instrumental activities of daily living or unrelated to needs because of a cognitive impairment, and has denied benefits
• The insurance company hired its own doctor to review your claim, or to examine you, and now is asserting that their doctor finds that you do not qualify for long-term care benefits, even though your doctor is stating that you do
• The insurance company has denied certain types of long-term care provided, asserting that you did not need the level of care that you were provided
• The insurance company states that you have not provided sufficient ongoing verification of long-term care needs and thus has denied benefits
• You suffer from a pre-existing condition, and thus the insurance company is denying your benefits
• The insurance company asserts that your medical condition is not covered because it is the result of one of the following — mental illness, attempted suicide or intentionally inflicted injury, alcoholism or drug addiction, war or acts of war — and denied your claim
• The insurance company has denied your benefits because it asserts that you have received care in a government facility or outside of the United States and its territories

Appealing a Denial of Insurance Benefits: Defending Your Legal Rights

Many wrongful denials of insurance benefit claims can be overturned without the cost, frustration, and delay of filing a lawsuit, simply by supplying the right information and knowing how to respond to your insurance company’s accusations.

Understanding the common tactics utilized by insurance companies and recognizing their deceptive behavior is essential in securing your rights and preparing an effective response. Before you proceed, it is vital that you understand your rights and obligations under your insurance policy and the law that governs your claim.

If you fail to meet your obligations, you may unknowingly be fatally destroying your claim. Your response to your insurance company’s wrongful denial of your long-term care insurance claim depends on the law that governs your claim. Private insurance policies, purchased independently from your employment, will fall under your state’s contract law.

However, most group insurance policies, obtained as a product of employment (whether you pay your premiums or your employer pays the premiums), fall under the federal statute, ERISA. Both types of claims have unique and specific requirements for claimants in responding to their insurance company’s wrongful denial.

How Long-Term Care Insurance Companies Evaluate Ongoing Eligibility

One of the most challenging aspects of long-term care insurance claims is that approval is often not permanent. Even after benefits begin, insurance companies typically continue to monitor whether the policyholder still meets the policy’s terms.

This ongoing evaluation process can create uncertainty for individuals and families who are relying on those benefits to cover essential care.

Insurers may periodically request updated information, such as:

• Current medical records.
• Physician certifications.
• Care provider notes and logs.
• Updated assessments of activities of daily living (ADLs).
• Documentation of cognitive impairment.

While these requests may appear routine, they are often used to reassess eligibility and identify any basis to reduce or terminate benefits. Even small changes in a person’s condition or inconsistencies in documentation can become the focus of further review.

Why “Improvement” Is Often Used to Challenge Continued Benefits

In many long-term care claims, insurance companies look for signs that the policyholder has improved enough to meet the policy’s definition of eligibility no longer.

This can be particularly frustrating because improvement in a medical sense does not always mean independence in daily life.

For example:

• A person may show slight physical improvement but still require daily assistance.
• Cognitive conditions may fluctuate, with periods of clarity followed by confusion or impairment.
• A claimant may be able to perform certain tasks occasionally, but not safely or consistently.

Insurance companies may focus on isolated examples of ability, while overlooking the broader picture of ongoing need. As a result, benefits may be questioned or reduced even when the individual continues to require substantial care.

The Importance of Consistent Care Documentation

In long-term care claims, consistency across documentation is critical. Insurance companies often compare multiple data sources to identify discrepancies that can be used to challenge eligibility.

These sources may include:

• Medical provider records.
• Home health aide notes.
• Family caregiver observations.
• Insurance company assessments.
• Recorded statements or interviews.

If these records do not align, even unintentionally, the insurer may argue that the level of care being provided is not medically necessary or that the claimant’s condition is less severe than reported.

For families managing care, maintaining detailed and consistent records can be difficult. However, these records often play a central role in whether benefits continue uninterrupted.

Independent Assessments and In-Home Evaluations

Insurance companies frequently rely on their own assessments to evaluate long-term care claims. These evaluations may take place in the home or through interviews with the claimant and caregivers.

During these assessments, the focus is often on:

• Observing how the individual performs daily activities.
• Evaluating mobility, coordination, and cognitive function.
• Determining whether assistance is required or simply helpful.

These evaluations are typically brief and may not fully capture the day-to-day reality of the claimant’s condition. However, the conclusions drawn from them can carry significant weight in the insurer’s decision-making process.

In some cases, a single assessment may be used to justify a reduction or termination of benefits.

When Care Needs Do Not Fit Neatly Into Policy Definitions

Long-term care policies often rely on structured definitions, particularly for activities of daily living and cognitive impairment. However, real-life care needs do not always fit neatly within those definitions.

For example:

• A person may require supervision due to fall risk rather than inability to perform a task physically.
• Assistance may be needed to complete tasks safely, even if the task can technically be performed.
• Cognitive impairments may affect judgment and safety rather than basic task completion.

Insurance companies may interpret these situations narrowly, focusing on whether a task can be performed at all rather than whether it can be performed safely and consistently.

This gap between policy language and real-world care needs is a common source of disputes.

Financial Pressure and the Impact of Delayed Benefits

When long-term care benefits are delayed, reduced, or denied, the financial consequences can be immediate and significant. Long-term care services are often expensive, whether provided at home or in a facility.

Families may be forced to:

• Pay out-of-pocket for ongoing care.
• Reduce or change the level of care being provided.
• Rely on family members to fill caregiving gaps.
• Make difficult financial decisions under pressure.

Because these policies are intended to protect against exactly these situations, delays and denials can feel especially overwhelming.

How Disability Insurance Law Group Can Help With Long-Term Care Denials

Long-term care insurance claims involve more than submitting paperwork. They require a clear understanding of how insurers evaluate eligibility, how policy language is applied, and how to respond when benefits are questioned.

At Disability Insurance Law Group, our attorneys represent clients nationwide in long-term care insurance disputes. We understand how insurance companies approach these claims and the strategies they use to limit or deny benefits.

If your long-term care claim has been delayed, reduced, or denied, we can review your policy, evaluate the insurer’s position, and help you determine how to move forward.

You should not have to navigate this process alone, especially when the need for care continues regardless of the insurance company’s decision.

Let One of Our Long-Term Care Insurance Attorneys Fight for You

The law governing insurance benefit claims, including long-term care insurance, is complex and constantly changing. Our attorneys understand what is at stake when you must file a long-term care insurance claim. If you or a loved one is injured or is suffering from a serious illness that affects your ability to care for yourself, will you be able to collect benefits under your insurance policy to cover the cost of expensive long-term care services?

Will your insurance carrier abide by the policy terms and pay your claim? Your need for long-term care and the steep costs for this type of care do not stop if your insurance company denies your claim. How will you proceed when your family’s financial future is at stake?

We understand that the reason our clients pays premiums for these types of policies is to protect their family, their income and their future. Our cases are not typical cases – an individual and their family’s future is at stake.

We recognize that our clients will either be in financial distress if their insurance claim is denied or already are due to a denial of benefits. When a person is dealing with a prolonged illness, serious injury, or even death, they are facing one of the most difficult times in their life.

Contact Us For Delayed or Denied Claims for Long-Term Care at Disability Insurance Law Group

To discuss your legal needs with an experienced long-term care insurance lawyer, please contact us today to schedule a free and informative consultation by calling us toll-free at 954-989-9000 or by using our online contact form. Disability Insurance Law Group serves clients nationwide.