Facing a long-term care insurance (LTCI) claim denial from MetLife can be an overwhelming experience. After years of paying premiums, the expectation is that your policy will provide the protection you need when you are most vulnerable. Unfortunately, insurance companies, including large providers like MetLife, do not always uphold their commitments, leaving policyholders in challenging situations.
MetLife actually exited the long-term care insurance market years ago, meaning all current policyholders are holding legacy contracts—often with outdated terms and confusing limitations that insurers are quick to exploit.Despite stepping away from long-term care insurance sales, MetLife continues to manage and process claims for thousands of in-force policies issued in the 1990s and early 2000s.
At Sandstone Law Group, we are well-versed in the unique challenges of handling legacy long-term care insurance claims with MetLife. We understand both the historical context of these policies and the modern tactics insurers use to deny them. Our firm is dedicated to representing individuals and families who are wrongfully denied the benefits they’ve counted on for decades—and we fight to hold MetLife accountable..
What Is Long-Term Care Insurance?
Long-term care insurance is designed to help cover the cost of personal and custodial care for individuals who can no longer live independently due to chronic illness, disability, or cognitive decline. Unlike traditional health insurance, long-term care insurance pays for services that assist with activities of daily living, whether those services are provided in your home, in an assisted living facility, or in a nursing home.
The goal of long-term care insurance is simple: to provide financial support when daily life becomes unmanageable without assistance. But while the concept is straightforward, accessing these benefits can be anything but, especially when companies like MetLife do not pay claims.
Qualifying for Long-Term Care Benefits
Most long-term care policies, including those issued by MetLife, require policyholders to meet one of two criteria:
- Physical impairment: The individual must be unable to perform at least two out of six Activities of Daily Living (ADLs) without substantial assistance.
- Severe cognitive impairment: The individual must suffer from mental decline that creates safety risks or requires continuous supervision, even if they can still manage activities of daily living.
These ADLs are standard benchmarks used to determine eligibility for long-term care, but may differ depending on the policy:
- Bathing: Safely getting in and out of a tub or shower and maintaining personal hygiene.
- Dressing: Putting on and taking off clothing, including fastening zippers and buttons.
- Eating: The ability to feed oneself, not cooking, but getting food to the mouth and swallowing.
- Transferring: Moving between positions, such as from bed to chair or standing from a seated position.
- Toileting: Using the toilet independently and maintaining necessary hygiene.
- Continence: Controlling bladder and bowel function, or managing assistive devices as needed.
If a person is physically limited in two or more of these areas or is cognitively impaired to the point that they need supervision, they may qualify for benefits under a long-term care policy.
MetLife’s History in Long-Term Care Insurance
Long-Term Care Insurance (LTCI) is designed to cover the costs of services that help with ADLs for individuals with chronic illness or disability. These policies are distinct from long-term disability insurance, which provides income replacement. With long-term care insurance policyholders contribute hard-earned money with the expectation that, in the event of functional or cognitive impairment, they will receive the promised support for services such as nursing home care, assisted living, or in-home care. Regrettably, this expectation is not always met.
MetLife may have exited the LTCI market in 2010, but the policies they continue to service impact thousands of policyholders today. One of the more notable legal disputes was a class action lawsuit over its “Reduced-Pay at 65” rider, a policy feature that led to confusion and unexpected costs for some retirees, sparking litigation over alleged misrepresentations.
The rider promised that policyholders who paid higher premiums before turning 65 would enjoy significantly reduced payments afterward. But instead of stability, many were blindsided by premium hikes reportedly as high as 102%, forcing seniors to choose between:
- Paying inflated premiums they could not afford,
- Reducing benefits they had counted on, or
- Letting their policies lapse entirely.
These issues led to the Newman v. Metropolitan Life Insurance Company class action lawsuit. The “Reduced-Pay at 65” scandal is part of a larger pattern in MetLife’s LTCI conduct. While MetLife denied wrongdoing, the case highlights broader challenges in the long-term care insurance industry where insurers underestimated the cost of providing care, and instead of correcting its pricing models, appear to have shifted the burden onto policyholders through:
- Sudden rate increases,
- Narrow policy interpretations, and
- Aggressive denial strategies.
Regulators and plaintiffs have expressed concerns that insurers are targeting retirees at a financially vulnerable time and undermining the very purpose of long-term care insurance: to protect policyholders in their most vulnerable years.
Common Reasons MetLife Uses to Deny Long-Term Care Insurance Claims
Long-term care insurance should provide peace of mind. But for many MetLife policyholders, the promise of support turns into a gauntlet of red tape, miscommunication, and denials. At times it appears that the companies managing long-term care insurance claims are acting within a broader pattern of obstruction used to delay or avoid paying legitimate claims.
1. Denials Based on Disputed “Need” for Care
One of the most frequent ways insurers like MetLife deny claims is by arguing that the policyholder does not “truly” need care, even when family members, physicians, and professional caregivers say otherwise. They rely on brief, one-time evaluations or Benefit Eligibility Assessments (BEAs) to paint an incomplete picture of the policyholder’s daily struggles.
Even when a person clearly needs help with Activities of Daily Living (ADLs) or suffers from cognitive impairment, insurers like MetLife may claim the support is not frequent enough or dismiss cognitive symptoms as mild. These denials often ignore the real safety risks and the lived experiences of both patients and their caregivers.
2. Policy Lapses Due to Premium Disputes or Notification Failures
Insurers like MetLife are often quick to point to a missed payment or a lapse in coverage as a reason to deny a claim, but can be slow to take accountability for administrative failures. Policies by insurers are often canceled without proper notice, in direct violation of legal requirements. In other cases, lapses result from an insurer’s own processing errors or the policyholder’s cognitive decline, which should be a red flag, not a disqualifier.
Even when a mistake is discovered before care begins, insurers like MetLife may force you to reapply for coverage instead of reinstating the original policy, effectively leaving you uninsured when you need it most.
3. Disputes Over Covered Services and Care Providers
Insurers like MetLife often try to narrow the definition of what counts as covered care. They may deny claims based on where the care is provided (home vs. facility), who provides it (family vs. licensed provider), or how it is categorized (custodial vs. skilled). These disputes can stretch on for months, leaving policyholders and families to shoulder the cost of care while navigating an opaque and unforgiving claims process.
For example, insurers like MetLife may agree that a policyholder qualifies for long-term care, only to argue that the caregiver is not “authorized” under the policy, even if that care is essential and professionally administered.
How Sandstone Law Group Can Help
Challenging a MetLife long-term care insurance claim denial requires aggressive and strategic legal representation. At Sandstone Law Group, our commitment is to fight for the benefits you have paid for and rightfully deserve.
Here’s how our dedicated team can assist you:
- Thorough Case Evaluation: We meticulously review all relevant documents, including your MetLife policy, medical records, and the denial letter. This comprehensive assessment helps us identify any discrepancies, errors, or missing information that may have led to the denial, as well as opportunities to strengthen your case.
- Aggressive Advocacy and Negotiation: We are known for our firm advocacy on behalf of our clients. We engage with insurance companies to challenge unfair practices and tirelessly pursue the benefits you are entitled to. While we aim for a fair resolution through negotiation, we are fully prepared to litigate if necessary to protect your rights.
- Litigation Experience: Our experienced litigators are well-versed in insurance litigation and approach each case with tenacity. We leverage our courtroom experience to present a compelling case and advocate vigorously for your rights in a legal setting.
Why Choose Sandstone Law Group?
At Sandstone Law Group, we fight to restore dignity, safety, and financial security to individuals and families who have been wrongfully denied long-term care benefits.
Long-term care insurance is supposed to provide support when it is needed most, not create new burdens. Yet far too often, insurers delay, underpay, or outright deny valid claims. That is where we come in: with experience, resolve, and a deep commitment to holding insurers accountable.
- We Listen First: From your first call, you will meet attorneys who listen with compassion and clarity. You will never be rushed through your story or treated like a file number. We create space for you to be heard, and from that place of understanding, we build a legal strategy that reflects the full truth of your condition, your care needs, and your policy rights.
- We Know MetLife’s Playbook: Our team has extensive experience confronting MetLife and other major insurers over long-term care denials. We understand the exact tactics used to avoid payment: biased assessments, vague denials, and narrow policy interpretations. We know how to dismantle them. Whether the issue involves disputed ADLs, cognitive impairment, policy lapses, or coverage gaps, we are prepared to fight back.
- We Are Built for Litigation: Some firms aim for quiet settlements. We prepare every case as if it will go to trial. That reputation forces insurers to treat our clients with the seriousness they deserve. And when trial becomes necessary, we have the litigation experience and results to see it through.
- We Win: Our attorneys have secured life-changing results for clients facing financial ruin after a denied claim. Whether by negotiation or in court, we do not stop until we have done everything possible to get our clients the care they were promised.
Contact Sandstone Law Group Today
If you have received a denial from MetLife for your long-term care insurance claim, this is not the time to wait and see what happens next. These policies were meant to protect your future, not become another obstacle during a time of vulnerability. When MetLife delays, underpays, or refuses to honor valid claims, you deserve more than generic answers, you deserve a powerful legal team that will take your fight seriously.
At Sandstone Law Group, we understand the real-life consequences of wrongful denials. Every day that benefits are withheld puts your health, your financial stability, and your peace of mind at risk. That is why we act quickly, decisively, and relentlessly on behalf of our clients. Whether your claim was denied due to an ADL dispute, a cognitive impairment dismissal, a policy lapse, or a coverage disagreement, we know the tactics MetLife uses and we know how to push back.
Our attorneys will carefully assess your situation, explain your legal options, and build a strategic case based on your lived experience, medical reality, and policy rights.
You do not have to face MetLife alone. Let us help you enforce the promises you paid for and ensure the care you need is not unjustly delayed or denied. Call us at (602) 902-1342 today for a confidential consultation.