Long-Term Care Insurance Denial

In the event that you or a loved one lose their autonomy and are dependent on someone else for activities of daily living, a long-term care insurance policy can provide the funding required to cover the expenses associated with assisted living. The benefit payments vary and depend on the details of your policy.

Long-term care is expensive, and as a result, insurance companies will scrutinize every claim, many of which result in denial. 

Benefits can be denied if you fail to meet the insurance company’s definition of being functionally dependent and requiring substantial physical assistance. For example, the diagnosis for cognitive impairment was not made by the correct doctor, or you are dependent because you require stand-by assistance to perform activities of daily living.

If your insurance company has denied your claim, you need to contact a law firm with experience dealing with long-term care insurance cases. Foisy and Associates is committed to ensuring that you receive the benefits to which you are entitled.

If your long-term care insurance claim has been denied or terminated, contact us for a free consultation. Call us at (905) 286-0050 or fill out our form on this page.

Long-Term Care Insurance Frequently Asked Questions

How do insurance companies determine dependency in long-term care insurance policies?

In long-term care policies, insurance companies determine that a person is dependent if they cannot perform two or more activities of daily living without substantial assistance. Or if the insured person needs constant supervision due to cognitive impairment to protect themselves from threats to their safety and health.

How are activities of daily living defined in long-term care insurance policies?

Activities of daily living are defined in long-term care insurance policies as specific daily tasks that the insured person needs to perform without substantial assistance from another person to maintain their health and safety. 

Activities of daily living are commonly defined in long-term care policies as:

• Bathing: The ability to wash your body in a bathtub (including getting in and out), shower (including getting in and out), or a sponge bath.
• Dressing: Putting on and taking off all necessary items of clothing and any medically necessary braces for artificial limbs. A person does not meet the definition of dependency if they are able to dress with substantial physical assistance by making alterations or changes to the clothing.
• Eating: The ability to feed yourself from a cup, bowl, plate, or a feeding tube. This does not include cooking or preparing a meal.
• Toileting: Getting to and from, and on and off the toilet, and performing associated personal hygiene.
• Transferring: Moving in and out of a bed, a chair, or a wheelchair.
• Continence: Controlling both the bladder and bowel functions, or if they cannot maintain control, the ability to perform the associated personal hygiene (including caring for catheter or colostomy bag).

In some long-term care policies, the insured may be entitled to stand by assistance from another person to perform two or more activities of daily living. Stand-by assistance means the other person is within arm’s reach of the insured when the relevant activity of daily living is being performed.

How is cognitive impairment commonly defined in long-term care insurance policies?

In long-term care insurance policies, cognitive impairment is commonly defined as the loss of, or deterioration in, intellectual capacity. To meet the definition of dependency, the insured person must meet the following three conditions:

1.The impairment must result from an organic brain disorder such as Alzheimer’s, irreversible dementia, or brain injury.

2.Dependency must be demonstrated by impairment in:

• short-term or long-term memory
• orientation as it relates to people, place and time
• reasoning, or
• judgement, as it relates to safety awareness

3.The diagnosis must be confirmed and measured by a specialist licensed and practicing in Canada or the United States, based on:

• clinical examination
• radiological studies, or
• psychological testing

How are benefits calculated in long-term care insurance policies?

Depending on the long-term care insurance policy, the insured person may be entitled to a lump-sum or monthly payout for your benefits. The insurance company determines benefits based on the number of days you are dependent and reside in either a “facility” or “not a facility” care setting.  The insurance company may require additional assessments or other proof that the insured person is still functionally dependent.

When can a long-term care insurance policy claim be denied?

Based on the long-term care policy, the insurance company can deny a claim based on:

• The insured person does not meet the insurance companies’ definition of being dependent.
  • They are able to perform at least five of the six activities of daily living without substantial assistance.
  • Their cognitive impairment is not the result of an organic brain disorder such as Alzheimer’s, irreversible dementia, or brain injury.
• The person providing assistance is not qualified to do so by the insurance company.
• The insurance company does not acknowledge the need for stand-by assistance for the insured.

When do insurance companies stop paying benefits for long-term care insurance policies?

Insurance companies will stop paying long-term care benefits on the date the insured person:

• is no longer dependent
• is no longer under the continuous care of a physician
• does not make reasonable efforts or refuses to participate in any appropriate rehabilitation program that is available to them
• no longer satisfies all of the conditions to qualify for benefits, or
• dies

For a benefit period limited by a maximum number of weeks, the insurance company stops paying benefits when the maximum is reached.

How long do you have to dispute a long-term care insurance denial?

The Limitations Act in Ontario states that the insured person must sue or commence an action within two years from the date when the benefit is denied. If the contract stipulates that denial will be less than two years, the insured person will have that reduced length of time to sue or commence an action.

If your long-term care insurance claim has been denied or terminated, contact us for a free consultation. Call us at (905) 286-0050 or fill out our form on this page.