When people invest in long-term care (LTC) insurance, they expect it to provide financial relief during some of life’s most challenging moments – when aging, illness, or disability make everyday living difficult. But many are shocked to discover their long-term care claims are denied.
If you’ve experienced denied long-term care insurance claims, it’s essential to understand the common reasons behind denials, what rights policyholders have, and how the appeals process works.
Statistics of Denied Long-Term Care Insurance Claims
Data from the 2022 Milliman Long-Term Care Insurance Survey reveals a stark reality: many long-term care insurance applications are denied from the outset.
- Ages 40–49: 12.4% claims are denied
- Ages 50–59: 20.4% claims are denied
- Ages 60–64: 30.4% claims are denied
- Ages 65–69: 38.2% claims are denied
- Ages 70-74: 47.2% claims are denied
These figures demonstrate how age can significantly impact approval rates, often due to underlying health conditions or risk factors flagged during underwriting. But even after a long-term care insurance policy is issued, claims may still be denied later, long after premiums have been paid.
Why Long-Term Care Insurance Claims Get Denied
Long-term care can be expensive, yet related costs continue to rise in the United States – alongside the never-ending denial of some (if not most) long-term insurance claims.
Here are some of the reasons why long-term care insurance claims are denied:
Insufficient Documentation
Many denials stem from incomplete, inconsistent, or unclear medical records. For instance, daily caregiver notes, treatment records, or care plans may be missing or fail to match the insurer’s criteria. Insurance companies may claim they never received the required forms or dispute the care provider’s qualifications.
Disputes Over Medical Necessity/Functional Impairment
Long-term care policies typically require the insured to be unable to perform at least two Activities of Daily Living (ADLs), such as bathing, dressing, or toileting, or to suffer from cognitive impairment. If the insurance company disagrees with the doctor’s certification or claims there is insufficient evidence of impairment, they may deny the claim.
Some insurers require documentation from specific healthcare providers or certified assessors. If the policyholder submits evaluations that don’t meet the insurance company’s strict standards, the claim may be rejected.
Failure to Meet “Benefit Triggers.”
To qualify for benefits, policyholders must meet the policy’s “benefit trigger” – a medical condition or functional limitation that initiates eligibility. These triggers are often tied to ADLs or cognitive decline. However, insurers may argue that the condition does not yet meet the threshold for coverage, especially if the need for assistance is occasional or intermittent.
Waiting Period Not Met
Most long-term care policies have a waiting period, also known as an elimination period, ranging from 30 to 90 days. Some policies only count the days on which paid care is received (service days), rather than calendar days. If the policyholder has unpaid caregivers or intermittent care, the waiting period may be extended, delaying benefits or leading to outright denial.
Pre-Existing Conditions
Insurers can deny claims by arguing that the condition requiring care was pre-existing and thus excluded. While California policies must clearly disclose exclusionary periods, these clauses are still used to contest benefits, especially for degenerative conditions that may have been undiagnosed at the time of application.
Lack of Coverage at Time of Claim
Coverage lapses due to missed payments or misunderstood policy expiration terms can also result in a denied long-term care insurance claim. Some insurers send minimal notice before terminating a policy, especially for elderly policyholders with memory issues.
Non-Covered Services or Settings
Some policies cover only institutional care (such as skilled nursing facilities), while others are limited to home-based services. A denial may occur if the care was received in an unlicensed facility or from an unapproved provider, even if the policyholder was otherwise eligible. Some long-term care policies may also impose outdated benefit limits, such as lower caps for assisted living or the exclusion of adult day care programs altogether.
How to Appeal After a Long-Term Care Insurance Denial
If your long-term insurance claim was denied, you are not without options. California law offers policyholders a pathway to appeal and contest a denial.
Request a Written Explanation
Under the California Insurance Code, insurers must provide a written explanation for any denial. This includes the specific reasons for the refusal and any policy language supporting it. Review this carefully to understand the basis of the dispute.
Review the Policy in Detail
Examine your policy for key provisions, including:
- Definitions of disability and benefit triggers
- Covered services and providers
- Elimination period and benefit caps
- Requirements for medical certifications
Gather Comprehensive Documentation
To counter the denial, collect:
- Updated medical records and physician statements
- Functional assessments that show ADL limitations
- Caregiver logs or notes
- Provider licenses and invoices
- Evidence of timely premium payments
Submit a Formal Appeal
Most insurers allow internal appeals. This usually involves submitting a written appeal with supporting documentation by a specific deadline. If the appeal is denied again, you may file a complaint or pursue legal action.
Consistency and specificity are crucial when appealing a denied insurance claim. A long-term care insurance lawyer can help ensure your appeal meets the insurer’s evidence standards.
Entrust a Denied Long-Term Care Insurance Claim to a Lawyer
Appealing an LTC insurance denial is time-sensitive and can be legally technical. Insurers may rely on internal guidelines, contracted third-party reviewers, and complex policy language to maintain their position.
Many claimants give up after a single denial, but the reality is that many appeals succeed with proper legal guidance.
A long-term care insurance claim lawyer can:
- Analyze the policy’s legal terms
- Challenge improper interpretations or bad-faith conduct
- Coordinate with physicians and care providers to develop stronger records
- Represent you in appeals, negotiations, or litigation
At The Law Offices of Kevin M. Zietz, we have proven experience in helping our clients with long-term care and disability insurance disputes in California. Call us today to schedule a free consultation and get started on your appeal.
It may seem tempting to appeal a long-term disability claim decision without legal assistance, but doing so can have lasting consequences. Appealing involves more than filling out paperwork or telling your story; it’s a legal process that requires strategy, a thorough understanding of disability policies, medical evidence, and experience with how insurance companies operate.
If you’re facing a denied long-term disability claim, an experienced disability lawyer can be the difference between another rejection and getting the benefits you’re rightfully owed.
What to Know About Long-Term Disability Denials
Long-term disability insurance is designed to protect your income when a health condition prevents you from working full-time. Despite paying premiums for years, claimants often find themselves unfairly denied coverage.
Insurance companies may base their denials on reasons such as:
- Lack of sufficient medical documentation
- Claims that you don’t meet the policy’s definition of “disability”
- Disagreements between your doctor and the insurer’s medical reviewers
- Alleged “pre-existing condition” exclusions
- Missed deadlines or incomplete paperwork
It’s essential to recognize that insurance companies don’t profit by approving long-term disability claims. Their interests are not aligned with yours, and their decisions are often crafted to protect their own well-being rather than yours.
What’s at Stake in Your Long-Term Disability Appeal?
If your initial claim is denied, you typically have the right to file an administrative appeal, especially if your LTD policy is governed by the federal law known as ERISA (Employee Retirement Income Security Act).
This appeal is your first and sometimes only chance to build a complete record for your case. That’s because, under ERISA, once the administrative appeal process is over, your legal rights change significantly; you can file a lawsuit in federal court.
Without a long-term disability claim lawyer guiding your appeal, you risk submitting an incomplete or unpersuasive file, closing the door on vital legal arguments later.
Why Legal Representation Is Crucial at the Appeal Stage
You Need to Strengthen the Administrative Record
Insurance carriers often deny LTD benefits due to a perceived lack of medical evidence. A long-term disability lawyer will work with your treating physicians to prepare detailed medical statements, request relevant records, and ensure all functional limitations are clearly documented. Lawyers know what insurance companies look for and what federal courts expect to see.
Strict ERISA Rules
The ERISA appeals process is filled with strict deadlines and procedural rules. Miss one, and your appeal could be dismissed. A long-term disability claim lawyer will ensure every step is completed on time and in compliance with ERISA requirements. They can also challenge procedural errors made by the insurer during the initial denial.
Understanding the Policy Language Is Key
LTD policies are notoriously difficult to interpret. They often include terms such as “own occupation,” “any occupation,” “regular care,” or “objective evidence,” and their meanings aren’t always clear. A long-term disability lawyer will interpret the policy language in your favor and argue that your condition meets the plan’s definition of disability.
Doctors Don’t Always Know How to Write a Supportive Report
It’s common for treating doctors to undermine a patient’s case unknowingly. They may omit crucial details about your functional limitations, use vague language, or fail to address key aspects of your daily limitations. A lawyer can guide your doctor through the process, helping them prepare letters that meet insurer expectations and hold up under scrutiny.
Appeals Involve Legal and Medical Strategy
An effective appeal weaves together medical records, policy language, and legal arguments into a compelling case. It’s not just about proving you’re disabled; it’s about proving that the insurance company had no reasonable basis to deny your claim. That requires strategy and experience.
Common Mistakes People Make Without a Lawyer
When individuals try to appeal a long-term disability decision on their own, they often make critical errors that weaken their case:
- Failing to request a complete copy of the claim file and policy
- Not submitting updated or supporting medical records
- Writing personal narratives without evidentiary support
- Relying too heavily on emotional pleas rather than legal standards
- Missing deadlines or using the wrong appeal procedures
- Not addressing the specific reasons listed in the denial letter
These mistakes may seem small, but they can be fatal to your appeal.
ERISA-Governed Policies vs. Individual Policies
It’s important to know whether ERISA governs your LTD policy or is a private individual policy. Group plans offered by employers are ERISA-governed, while individually purchased plans are not. A qualified long-term disability claim lawyer can identify the governing law and tailor your appeal strategy accordingly.
When to Call a Long-Term Disability Lawyer
You should consult a disability lawyer as soon as your LTD claim is denied. The clock starts ticking immediately, giving you only 180 days to appeal. Waiting too long or submitting an incomplete appeal could cost you the benefits you deserve.
Your long-term disability lawyer will:
- Collect medical evidence and secure expert opinions
- Draft legal arguments tailored to your policy and circumstances
- Identify procedural errors that could invalidate the denial
- Communicate with the insurance company on your behalf
- Prepare your case for litigation, if necessary
Don’t let a denial letter stop you from getting the support you’re entitled to. If you’ve received a denial and need help with your appeal to a long-term disability decision, reach out to a long-term disability lawyer in California who can stand up to the insurance company and protect your rights.
At The Law Offices of Kevin M. Zietz, our attorney is equipped to handle disability claim appeals without legal fees until you get your benefits. We handle long-term disability claims and appeals and understand how to work with both group and individual LTD policies. Contact us today to schedule a free consultation and get started on your appeal as soon as possible.
Long-term care (LTC) insurance covers the costs of nursing home and/or assisted living services. Under most long-term care policies, a person is eligible for benefits when they are not able to do at least two out of six “activities of daily living” without the assistance of a home health professional, or they suffer from dementia or other cognitive impairment. The activities of daily living are:
- Bathing.
- Caring for incontinence.
- Dressing.
- Eating.
- Toileting (getting on or off the toilet).
- Transferring (getting in or out of a bed or a chair).
LTC insurance is expensive. According to the Alzheimer’s Association, the estimated cost for end-of-life care in 2019 ranged between $233,000 and $367,000. Most health and disability insurance will not cover long-term care, but long-term care insurance will.
Long-term care insurance policies may have limits on how long or how much they will pay. Some policies will pay the costs of long-term care services for two to five years, while other insurance companies offer policies that will pay for a person’s long-term care costs for as long as they live, regardless of cost.
Unfortunately, in the ongoing effort to cut their costs, insurance companies routinely deny valid LTC insurance claims based on technical requirements in the policies. Insurance companies also deny LTC claims by disputing that a person’s medical condition requires the level of care covered by the LTC policy, or by suggesting that those seeking benefits are receiving more care than is necessary or have been placed in the wrong type of facility.
If you have questions about what your options are after an insurance company has denied a claim for LTC benefits, call attorney Kevin M. Zietz for a free consultation.
When someone becomes unable to work due to injury or illness and goes out on disability, there may be sources of income replacement available through the State that you live in and/or the federal government. Only a handful of states have a State Disability Insurance Program, and the Social Security Administration provides federally funded programs to assist disabled workers.
State Disability Insurance Program (SDI)
Five states (California, Hawaii, New Jersey, New York, Rhode Island) and Puerto Rico, have State Disability Insurance (SDI) programs. These programs are designed to partially replace wages for workers who are very ill, injured off the job, and unable to work. If someone is disabled for less than one year, a state disability program may be the only source of disability benefits through a government entity.
In California, the Employment Development Department (EDD) provides short-term wage replacement benefits to eligible workers who have a loss of wages when they are unable to work due to a non-work-related illness, injury, or pregnancy.
The EDD will pay SDI for as long as you remain disabled, up to a maximum of 52 weeks.
Social Security Disability Income (SSDI)
Social Security Disability Insurance (SSDI) is a federal program administered by the Social Security Administration. This program will pay benefits to a disabled person and certain family members if they are “insured,” meaning they have worked long enough, and recently enough, and paid Social Security taxes on their earnings.
In order to satisfy the definition of disability under the Social Security Administration’s rules, the person claiming to be disabled must have a medical condition that makes it such that you cannot do the work that you did before because of a medical condition, and you cannot adjust to other work because of your medical condition. Furthermore, the disability must last or be expected to last for at least one year or to result in death.
A person’s financial status is not a factor in determining whether they qualify for SSDI. In other words, if a person satisfies all of Social Security’s criteria to receive SSDI benefits, the fact that they are financially secure does not play a factor in determining whether they are eligible for benefits.
Supplemental Security Income (SSI)
The Supplemental Security Income (SSI) program is also administered through the Social Security Administration. The SSI program provides monthly payments to adults and children with a disability or blindness, and who have income and resources below specified amounts. A person may be able to receive SSI if their resources have a value that is $2,000 or less. A couple may be able to receive SSI if they have resources worth $3,000 or less.
SSI payments can also be made to people 65 and older without disabilities who meet the financial requirements for these benefits.
The bottom line is that to qualify for SSDI, you must meet the Social Security Administration’s criteria for disability. Whether you qualify for SSI depends on your income and resources. A person does not necessarily need to be disabled to receive SSI.
The Long-Term Disability Carrier Wants Me to Apply for Social Security Disability – Am I Required to Apply for Social Security Disability?
If you are currently receiving Long-Term Disability (LTD) benefits under a group sponsored by your employer, or if you are dealing with a claim that has been denied, the claim administrator (usually an insurance company funding the plan) has probably informed you that you are required to apply for Social Security Disability Income (SSDI). It is important that you review the insurance policy, specifically the “offset provisions” that describe what other sources of income the disability insurance company is entitled to subtract from your monthly LTD benefit.
What is an offset?
An offset is money that you are receiving from another source (i.e., State Disability, Workers’ Compensation Benefits, SSDI, a retirement benefit, etc.) that the policy subtracts from your monthly LTD benefit. The policy will identify all sources that it is entitled to offset from your monthly LTD benefit. SSDI is a common offset that you will see in disability insurance policies insuring a group disability plan.
Why Am I Required to Apply for Social Security?
If you are potentially entitled to receive an award of SSDI, the LTD policy will probably require that you actively pursue this benefit. If you chose not to apply for Social Security, and you have been approved for LTD benefits, the policy’s offset provision will typically entitle the claim administrator to estimate your monthly SSDI benefit and offset it from your LTD benefit. In other words, if you are receiving LTD benefits and you decide not to pursue SSDI, the LTD carrier may be permitted (pursuant to the terms of the policy) to subtract money from your monthly LTD benefit that you are not actually receiving (but were potentially entitled to receive). Therefore, it is generally not a good idea to forego applying for SSDI if the LTD policy requires that you apply for it.
One reason that you may want to delay the application for Social Security is that you do not have sufficient medical evidence to support your claim. You should consult an experienced Social Security lawyer about when it is proper to apply for SSDI.
What Happens if I Have Been Receiving LTD Benefits for Months or Years and
Then I Receive a Retroactive Award of SSDI.
If your LTD claim is approved before your SSDI claim has been approved, or before you apply for SSDI, the claim administrator on the LTD claim will decide how to handle the offset issue. If you provide the claim administrator on the LTD claim with proof that your SSDI claim is pending, they will generally pay the monthly LTD benefit without offsetting an estimated SSDI benefit. However, as indicated above, if you do not apply for SSDI, the claim administrator will ultimately be entitled to estimate your SSDI benefit and deduct it from your monthly LTD benefit.
If you have been receiving a monthly LTD benefit without offset, and then you receive a retroactive award of SSDI, it will create an overpayment situation. In other words, you will owe some or all the retroactive award from the Social Security Administration back to the claim administrator on the LTD claim. The reason that you owe the LTD claim administrator money back is because you were overpaid in each month that you have already received an LTD benefit and now have been paid SSDI retroactively. If you have been receiving LTD benefits for several months, or maybe years, without SSDI being offset, and now you have been awarded SSDI, it will be important for you to contact the claim administrator on the LTD claim after you receive your benefits from Social Security. If there has been an overpayment, you will owe some or all the retroactively awarded money received from Social Security back to the claim administrator on the LTD claim.
Can Being Approved for SSDI Help My LTD Claim?
If your SSDI claim has been approved, the claim administrator on the LTD claim will not be bound by the decision made by the Social Security Administration. Likewise, if your LTD claim has been denied on appeal and you sue the LTD carrier and LTD plan in federal court, the court will not be bound by the decision made by the Social Security Administration. Nevertheless, the decision by the Social Security Administration may be offered as persuasive evidence in support of your LTD claim at the administrative appeal stage (when the claim administrator is reviewing your appeal). Even if your appeal is ultimately denied, and you sue in federal court, you will want the Social Security Administration’s decision to approve your SSDI claim to be a part of the LTD claim administrator’s file (the administrative record) so that it can be referenced by the court in that case.
If you have been denied by the claim administrator on the LTD claim at a point where the “own occupation” definition of disability is applicable, the SSDI award could carry significant weight because the Social Security Administration uses a more stringent “any gainful occupation” standard as part of its criteria it uses for awarding disability benefits.
What If I Have Been Denied Social Security Disability Income Benefits?
On average, the Social Security Administration denies nearly 60 percent of first-time SSDI applications. If you have been denied, it does not necessarily mean that you are ineligible. It is an indication you need to provide the Social Security Administration with additional information to allow that agency to properly reevaluate your application. You should consult with an experienced Social Security lawyer who can assist with your request for reconsideration.
Why Was I Denied Social Security Disability Income?
If you have been denied SSDI benefits by the Social Security Administration, it could be for any one of several reasons. The reason for being denied could range from any of the following:
- You did not work enough quarters;
- Your condition was not deemed severe enough to prohibit you from working at your occupation;
- Your condition does not meet or equal one of the Social Security’s severe impairment listings;
- You are able to perform the important duties of another occupation, given your age, education, and job skills;
- You have an outstanding warrant for your arrest for certain felony crimes, you were convicted of a crime and will go to jail, or you violated your probation or parole.
You should consult with an experienced Social Security lawyer to review the reason(s) that your application for SSDI was denied. An attorney can assist you in filing an appeal and represent you on your request for reconsideration. You must request an appeal in writing within 60 days of the Social Security’s decision, so it is imperative that you consult with a Social Security attorney as soon as possible.
If you have any questions regarding your claim for LTD benefits, and/or how an award of SSDI benefits may affect your claim, call Law Offices of Kevin M. Zietz for a free consultation.
If your long-term disability claim is governed by the Employee Retirement Income Security Act (ERISA), you are required to pursue an administrative appeal before you can file a lawsuit against the disability insurance carrier and the long-term disability plan. After your appeal rights have been exhausted, the next step would be to file a lawsuit in federal district court against the insurance company and the long-term disability plan. The law that developed since the enactment of ERISA in 1974 established that a denial of benefits challenged under ERISA’S civil enforcement provision must be reviewed under a de novo standard unless the benefit plan expressly gives the plan administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the plan’s terms. If the plan documents expressly give the plan administrator or fiduciary discretionary authority, the court is required to review your claim using a deferential standard of review.
If you have long-term disability coverage that was obtained through a group plan at work, and depending on which jurisdiction you reside, chances are that the policy grants discretionary authority to the insurance company. This simply means that a federal court reviewing the decision must give deference to the insurance company’s decision applying what is called an “arbitrary and capricious” standard of review. However, many states (i.e., California, Connecticut, Hawaii, Idaho, Illinois, Indiana, Kentucky, Maine, Maryland, New Jersey, New York, South Dakota, and Texas) have outlawed discretionary authority clauses found in group long-term disability plans.
Under the abuse-of-discretion standard, is it more difficult for a claimant to prevail in court? If the claim is subject to a de novo review, “The court simply proceeds to evaluate whether the plan administrator correctly or incorrectly denied benefits.” (Abatie v. Alta Health & Life Ins. Co. (9th Cir. 2006) 458 F.3d 955, 983.). California enacted Insurance Code §10110.6 effective January 1, 2012, which outlawed discretionary clauses in life, health, and disability plans.
Even if a group disability plan has an effective date before January 1, 2012, the policy insuring the plan will become subject to Insurance Code §10110.6 after renewal on the policy’s annual anniversary date after January 1, 2012.
When the Court utilizes a de novo standard of review, the Court evaluates whether the Plaintiff is disabled within the terms of the plan, and after evaluating the persuasiveness of conflicting evidence, decides which is more likely to be true. Kearney v. Standard Ins. Co., 175 F.3d 1084, 1095 (9th Cir. 1999) (en banc); Muniz v. Amec Const. Management, Inc., 623 F.3d 1290, 1295-96 (9th Cir. 2010).
Under a de novo standard of review, it is the Plaintiff’s burden to prove their disability by a preponderance of evidence. Muniz v. Amec Constr. Mgmt., 623 F.3d 1290, 1294 (9th Cir. 2010). This means it is the Plaintiff’s responsibility to produce evidence demonstrating that the plan administrator incorrectly denied benefits. The evidence must establish that the claimant satisfies the definition of disability in the policy. See Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 963 (9th Cir. 2006). Essentially, it is the court’s duty to determine whether or not the evidence supports disability.
If you are dealing with a disability claim that has been denied by an insurance company, contact the Law Offices of Kevin M. Zietz for a free consultation.
