Prudential Long-Term Care Insurance Denials

When you or your loved one invested in a Prudential long-term care insurance (LTC or LTCI) policy—often decades ago—you were not just purchasing a financial product; you were planning for one of life’s most vulnerable chapters. Prudential was one of the most prominent insurers in the LTC space. Today, however, Prudential no longer sells new LTC insurance policies, having exited the market in 2012. But for the thousands of policyholders still holding active coverage, especially those in states like California and Arizona, the promises made in those now-legacy contracts still matter.

Although Prudential is a large and well-established insurer that continues to manage many older long-term care policies, many policyholders have encountered significant challenges when seeking benefits. In many cases, claims have been denied based on potentially incorrect readings of policy terms, medical reviews that are later disputed, internal investigations related to “fraud, waste, and abuse,” or procedural issues arising from the complexity of the policy language. This results in elderly and disabled individuals being left without the care they need, while families scramble to fill the gap financially and emotionally.

At Sandstone Law Group, we understand the unique challenges Prudential policyholders face today—challenges that stem not only from the insurer’s current practices, but also from the long history and aging framework of these discontinued long term care (LTC) products. We represent individuals and families who have been wrongfully denied long-term care benefits by Prudential. If Prudential has denied or delayed your claim, we are here to challenge that decision and secure the care and coverage you were promised.

Understanding Long-Term Care Insurance

Long-term care insurance is, of course, not health insurance. Its purpose is to cover support services when a chronic illness, cognitive impairment, or disabling condition makes it difficult to live independently. This includes services provided in your home, assisted living facility, or nursing home, whether the care is custodial, rehabilitative, or supervisory.

Prudential long term care (LTC) insurance policies, like most others, often require policyholders to meet one of two criteria in order to be certified as Chronically Ill or Disabled:

1. The individual must have a loss of the ability to perform, without Substantial Assistance, at least two Activities of Daily Living (“ADL”) for a period of at least 90 consecutive days, or
2. A severe cognitive impairment, which requires Substantial Supervision to protect you from threats to health or safety.

The ADLs are mostly standard benchmarks used to determine eligibility for long-term care, but still fraught with potential ambiguity on what constitutes an ADL. Definitions can include the following:

• Bathing: Washing oneself by sponge bath, or in either a tub or shower, including the task of getting into or out of the tub or shower.
• Dressing: Putting on and taking off all items of clothing and any necessary braces, fasteners or artificial limbs.
• Eating: Feeding oneself by getting food into the body from a receptacle (such as a plate, cup or table) or by feeding tube or intravenously
• Transferring: Sufficient mobility to move into or out of a bed, chair or wheelchair or to move from place to place, either by walking, using a wheelchair or by other means.
• Toileting: Getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene.
• Continence: The ability to maintain control of bowel and bladder function, or, when unable to maintain control of bowel or bladder function, the ability to perform associated personal hygiene (including caring for catheter or colostomy bag).

If a person needs “substantial assistance” in two or more of these areas they may qualify for benefits under their LTC insurance policy. Substantial assistance can include hands-on or standby assistance, depending on the policy. The definition stems from Internal Revenue Code § 7702B(c)(2), part of HIPAA’s framework for tax-qualified long-term care insurance policies. 

Additionally, if a person is cognitively impaired (meaning a loss or deterioration in intellectual capacity) and they require oversight that may include cueing by verbal prompting, gestures, or other demonstrations by another person, and which is necessary to protect them from threats to their health or safety, they may qualify for benefits under an LTC insurance policy. This is referred to as “substantial supervision.”

Prudential’s History with LTC Insurance

Prudential Financial is one of the largest and most financially powerful insurance companies in the United States. As a Fortune 500 company with billions in annual revenue and a global footprint, Prudential is synonymous with stability and strength, but its treatment of policyholders may not always reflect those values.

While Prudential has long marketed its LTC products as financial lifelines for individuals facing serious illness or disability, its claims practices at times appear to prioritize profitability over people. The company has been named in class action lawsuits for alleged wrongful denials and benefit cutbacks and has paid out significant settlements in response to those claims. Yet due to its immense financial resources, Prudential at times appears able to absorb these legal costs as a cost of doing business, without making substantial changes to its claims handling behavior.

This institutional imbalance puts individual claimants at a serious disadvantage. When a valid LTC claim is denied, policyholders and their families are left to navigate complex policy language, narrow interpretations, and bureaucratic resistance, all while dealing with the emotional and logistical challenges of declining health or cognitive capacity.

We regularly see cases where insurers, like Prudential, will:

• Suddenly raise premiums which forces some seniors to reduce coverage or abandon policies
• Apply potentially incorrect definitions to policy terms to avoid paying claims
• Use rigid or incomplete benefit eligibility assessments to dispute ADL or cognitive impairments
• Claims are sometimes denied at the outset, a decision that can be difficult for policyholders to contest—particularly given the legal complexity involved and the time, cost, and expertise required to pursue litigation.

Our firm has experience navigating complex long term care insurance disputes, including with Prudential. In some cases we’ve handled, clients who appeared to meet all eligibility criteria were nonetheless denied benefits—often due to differing interpretations of ADL limitations or insurer positions that “standby assistance” did not qualify under the policy. We’ve also seen individuals whose policies lapsed following missed payments, sometimes linked to cognitive impairment—the very condition that gave rise to the need for care. In some instances, clients reported that they did not receive clear or timely notice of termination.

Common Tactics Prudential Uses to Deny LTC Claims

In our experience, the claims process with Prudential can involve procedures that many policyholders find challenging, stressful, or difficult to navigate. These may include:

1. Denying Care Based on Allegedly “Mild” Impairments

Prudential may argue that you do not qualify for benefits because your cognitive impairment or ADL limitations are “not severe enough.” Often, these assessments are based on short, arguably biased evaluations that ignore daily safety concerns and the recommendations of treating physicians.

2. Canceling Coverage Due to Lapses or Premium Errors

If a policyholder misses a payment, whether due to cognitive decline, administrative mistake, or mail errors, Prudential may cancel the policy without the legally required notice. They then may refuse to reinstate coverage, even if the need for care is urgent.

3. Rejecting Claims Based on Care Provider Definitions

Prudential might deny coverage by asserting that your caregiver is not properly licensed, even when the care is professional and medically necessary. This narrow reading of policy terms is used to withhold benefits under technicalities, not genuine disputes over care quality.

4. Delays, Red Tape, and Opaque Communications

From endless requests for documentation to sudden policy reinterpretations, Prudential’s process is often designed to wear down claimants. Many families give up or pay out of pocket while waiting, exactly what the insurer hopes for.

5. Using Internal Fraud Units Without Clear Standards or Training

Insurance companies like Prudential often have internal fraud investigation units that in some cases operate arguably without clear written procedures, adequate training, or proper oversight. Investigators may proceed without fully understanding the policy terms, without seeking exculpatory evidence, and without ensuring that their actions comply with fair claims practices. This lack of internal controls can lead to unsupported fraud accusations and significant delays in claim processing

6. Incentivizing Claim Terminations Through Strategic Initiatives

As part of a broader strategy to manage financial exposure from older long term care policies, insurance companies, like Prudential, may use departments such as a “Fraud, Waste, and Abuse” unit that tracks and arguably rewards claim terminations. In some companies internal performance evaluations for staff involved in looking for “Fraud, Waste, and Abuse” have emphasized metrics such as the number of fraud referrals and total “impact” in terms of dollars saved from terminated claims. This environment could create pressure to prioritize cost-cutting over objective and fair claim evaluation.

7. Employing Surveillance and Investigations in a One-Sided Manner

Investigative efforts may seem to focus on gathering evidence to support a denial while downplaying or excluding information that could support the claim. In some cases, surveillance is used without disclosure to the claimant during the appeal process, and key exculpatory evidence may be omitted from reports. These practices can tilt the process away from a balanced, good faith review of eligibility.

8. Continuing to Collect Premiums Even After Alleging Fraud

Even after denying claims and referring cases to state insurance departments for alleged fraud, insurance companies, like Prudential, have in some instances continued to collect monthly premiums from policyholders. This inconsistency raises concerns about the insurer’s internal decision-making and whether the fraud allegations are being used appropriately within industry standards.

Appealing a Prudential LTC Claim Denial

When your LTC or LTCI claim is denied by Prudential, your first instinct might be to file an appeal, but with some LTC policies, that is not always a legal requirement.

Complicating matters further, policies vary widely. Some include optional or informal appeal procedures, while others might require you to submit an appeal within 180 days. Additionally, many LTC or LTCI policies do not require an internal appeal at all.

Knowing whether to appeal, when to appeal, and how to craft a persuasive appeal requires a detailed understanding of your specific policy terms, the governing law, and the insurer’s claims-handling history. This is on a case-by-case basis.

Do not assume you have to appeal, and do not risk submitting one without legal counsel. If your Prudential long term care (LTC) claim has been denied, let our team review your policy, explain your options, and help you choose the best path forward.

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, Prudential and other insurers appear to 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: You will meet attorneys who listen with compassion and clarity. Attorneys Kyle Shelton and Erin Ronstadt will never rush through your story or treat you 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 Prudential’s Playbook: Our team has extensive experience confronting Prudential and other major insurers over long term care denials. We understand the exact tactics used to avoid payment: what we view as biased assessments, vague denials, and incorrect 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 court. 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, Kyle Shelton and Erin Ronstadt, 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.

How Sandstone Law Group Can Help

Challenging a Prudential long term care (LTC) 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 is how our dedicated team can assist you:

• Thorough Case Evaluation: We meticulously review all relevant documents, including your Prudential 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. Kyle and Erin have extensive court room and trial experience and are prepared to take your case as far as it needs to go.

Contact Sandstone Law Group Today

Delayed or denied benefits can force families to make heartbreaking decisions: pulling loved ones out of care facilities, taking on caregiving roles without proper training, or draining life savings to cover medical costs that should have been insured. You do not have to accept Prudential’s decision as final.

At Sandstone Law Group, we understand that every day without care puts your health, independence, and financial stability at risk. Our team will not only fight to reverse a wrongful denial, but we will build a strategy to hold Prudential accountable for the full value of what they owe you. Whether through aggressive negotiation or courtroom litigation, we are relentless in our pursuit of justice for policyholders who have been mistreated. Let us help you take back control.