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Understanding insurers' long-term care claim denials

Many elderly people need assistance with daily tasks as they get older, and this is especially true if the individual in question suffers from memory loss or other health problems. Long-term care is the right solution for many families, but it can be prohibitively expensive. According to the U.S. Department of Health and Human Services, it can cost as much as $205 a day to stay in a nursing home.

Long-term care insurance policies offer a reasonable solution for aging people who predict that they may later reside in such a facility. Insureds can pay a monthly premium for coverage later, but when it comes time to file a claim, the insurance company might deny it. Here is what you need to know in such a situation.

Provider’s eligibility

Insurers often impose strict criteria on the type of care providers that are eligible for coverage with policy benefits. You may need to submit documentation from the facility detailing what kind of staff it employs and what kind of care it provides. The insurance company may automatically deny a claim if an insurer assesses the facility you select to be ineligible.

Unpaid premiums

It is not uncommon for long-term care to become a necessity as a result of cognitive impairment. Unfortunately, cognitive impairment might also cause an insured to neglect payment of her or his premiums. If the insured has not submitted payment for several months, the policy may lapse, but proving that a health problem is to blame can help you combat the denial. 

Prior hospitalizations

These so-called gatekeeper provisions have been made illegal in many states, but some policies still exist which stipulate that the insured must have previously been hospitalized or stayed in a nursing home in order to have benefits paid out for long-term care. Some insurance even requires the satisfaction of both these criteria before disbursement of coverage funds.

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