California Long-Term Care Insurance Denials

Why Long-Term Care Claims Get Denied

Insurance companies deny claims for many reasons, some valid, many not. In California, where housing and healthcare costs are high, the financial stakes of a denial are often devastating. Here are some of the most common reasons insurers use to deny long-term care benefits:

1. Disputing the Level of Need

Insurers frequently claim that the policyholder does not require “substantial assistance” or “standby assistance” with two or more ADLs, even when caregivers and physicians strongly disagree. They may rely on biased assessments or one-time virtual nurse evaluations that do not capture the full scope of the person’s impairment.

2. Rejecting Cognitive Impairment Claims

Even when dementia or other cognitive conditions are clearly documented, insurers may argue that the impairment is not “severe” or that the individual poses no risk to themselves, despite family testimony or clinical evaluations.

3. Disputing the Care Setting or Provider

Many insurance companies may try to exclude certain types of caregivers, facilities, or certain types of services. Insurers may reject claims because:

• Care is provided at home rather than in a facility
• A family member is serving as a caregiver
• The provider lacks a specific type of certification

These technicalities often have little to do with actual need.

4. Claiming a Policy Lapse

Insurers may deny coverage due to missed premium payments, often overlooking the role of cognitive decline or their own administrative failures. California law requires clear notice and a grace period before terminating coverage, but some insurers ignore this requirement entirely.

5. Delays and “Lost” Paperwork

Deliberate or negligent delay is a form of denial. Requesting the same documentation repeatedly, failing to respond to inquiries, or dragging out evaluations are common tactics used to wear claimants down.

Do You Need to Appeal a LTC Denial in California?

Not always. While many disability and health insurance policies require administrative appeals, long-term care insurance does not always impose that requirement. Many policies do not include mandatory appeal clauses. Others may offer an appeal option, but do not require it before litigation.

Here is what you should know:

• Read the Policy First: Some LTCI policies include optional appeal rights with specific deadlines. Others do not address appeals at all.
• You May Have the Right to Sue Immediately: If the appeal is not required, an attorney may recommend proceeding straight to litigation.

The need to appeal has to be assessed on a case-by-case basis, where an experienced long-term care lawyer can review your policy, understand the governing law, and inspect medical evidence. This is why it is vital to hire an attorney before you consider an appeal.

Prudential, MetLife, Everlake, Allstate, and Other Insurers: Denials of Long Term Care Claims

California policyholders are often insured by major companies like Prudential, MetLife, Unum, Everlake, Allstate, Genworth, Bankers Life, and John Hancock, and each has a track record of aggressive denial strategies.

Prudential, for example, has faced lawsuits over improper denials and has been criticized for narrowly interpreting benefit triggers and care definitions. MetLife, while no longer issuing new LTCI policies, continues to deny claims under legacy contracts, sometimes decades after policyholders began paying premiums.

Insurers rely on the assumption that policyholders and their families will be too overwhelmed, under-informed, or exhausted to fight back. We work to prove them wrong.

How Sandstone Law Group Can Help

With deep experience in California long-term care insurance law, we provide full-spectrum support, including:

1. Policy Analysis and Claim Evaluation

We start by reviewing your policy, medical records, and denial letter. We assess whether you meet the benefit triggers, what documentation is missing, and how the insurer may have misinterpreted or misstated your eligibility.

2. Gathering the Right Evidence

We coordinate with doctors, care providers, neuropsychologists, and vocational experts to prove your functional limitations or cognitive impairment. We ensure that the evidence presented is strong, specific, and policy-aligned.

3. Handling Appeals and Litigation

If an appeal is necessary or strategic, we handle it with precision, preparing a detailed record that supports your claim and preserves your legal rights. If the insurer will not budge, we file suit and pursue your benefits through litigation.

Why Choose Sandstone Law Group?

At Sandstone Law Group, we understand the enormous trust you placed in your insurer when you signed that policy. Now that trust has been broken, you deserve a legal team that will treat your case with the urgency, respect, and legal force it requires.

Here is what sets us apart in long-term care insurance denial cases across California:

• We Listen First: From the moment you contact us, we take the time to hear your story, not just your policy number. We understand that every client’s needs, medical history, and caregiving circumstances are different. Whether your claim involves Alzheimer’s care, a stroke recovery plan, or mobility-related limitations, we work to understand your lived experience and how your care needs intersect with your policy language. Our legal strategy starts with your reality.
• We Know the Insurers’ Tactics: Whether your policy is with Prudential, MetLife, Unum, Everlake, Allstate, Genworth, Bankers Life, or another major carrier, we have seen their denial strategies and we know how to dismantle them. We are familiar with the vague explanations, the overly technical definitions, and the sudden “policy lapses” insurers use to justify nonpayment. We have taken on these companies before, and we do not back down.
• We Are Built for Litigation: While resolution is always our goal, we prepare every file as if it is headed to trial. That approach gives us the upper hand, and insurers know we are not bluffing. We pursue denied claims aggressively and, when appropriate, seek full discovery, testimony under oath, and trial verdicts to hold insurance companies accountable.
• We Deliver Results That Matter: Our attorneys have secured millions of dollars in long-term care benefits and legal damages for clients who were wrongfully denied coverage. Whether your policy was denied based on disputed ADLs, alleged lapses, or based on care received, we work to reverse that denial and get you the benefits you paid for.
• We Treat Clients Like Family: We understand the emotional and financial toll that a wrongful denial can bring, especially for elderly clients, adult children managing care, or spouses already overwhelmed. When you hire us, you are gaining a team that is compassionate, responsive, and dedicated. You will always know where your case stands, what we are doing next, and why we are doing it.