Experienced Long-Term Care Insurance Denials Attorneys
Long-term care insurance (LTCI) is meant to protect people during one of the most vulnerable periods of their lives, when illness, aging, or cognitive decline robs them of independence. Policyholders invest in these plans for years, often decades, expecting security when they can no longer care for themselves. But all too often, when the time comes to use their benefits, they are met with unexpected resistance, delay, or outright denial from their insurance company.
At Sandstone Law Group, we represent individuals and families across California, and all 50 states, who have been denied the long-term care insurance benefits they paid for. Whether your claim has been rejected due to alleged technicalities, questionable assessments, or vague exclusions, we are here to fight back and ensure you receive the care and dignity you deserve.
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What Is Long-Term Care Insurance?
Long-term care insurance is a policy that covers services needed when a person becomes unable to perform basic tasks of daily living due to chronic illness, physical disability, or cognitive decline.
LTCI is designed to pay for assistance with essential tasks, including:
- Bathing
- Dressing
- Eating
- Transferring (moving from a bed to a chair)
- Using the toilet
- Managing incontinence.
This care can be provided in a variety of settings, including:
- The policyholder’s home
- Assisted living facilities
- Nursing homes
- Adult day care centers.
The benefit of long-term care insurance is clear: it offers financial assistance to individuals who require ongoing help and support, helping preserve dignity, independence, and quality of life. Unfortunately, actually receiving those benefits is far from simple.
The California Standard for Qualifying
Under California law and most LTCI policies, a person becomes eligible for benefits when they are either:
- Unable to perform two or more of the six Activities of Daily Living (ADLs)without hands on or stand-by assistance, or
- Experiencing a severe cognitive impairment, such as Alzheimer’s or dementia, that places them at risk and requires supervision.
The Commonly Recognized ADLs Include:
- Bathing and Personal Hygiene: The ability to wash yourself, including getting in and out of a bathtub or shower, and maintaining personal grooming like brushing your teeth or shaving.
- Dressing: Being able to select appropriate clothing and put it on, including the ability to manage buttons, zippers, and supportive devices.
- Toileting: Getting to and from the toilet, using it properly, and cleaning oneself afterward.
- Continence: The ability to control bladder and bowel function, or to manage devices like a catheter or colostomy bag.
- Transferring: Moving in and out of a bed, chair, or wheelchair without assistance.
- Eating: The ability to feed oneself, not to be confused with cooking or meal preparation.
- Ambulating (in Non-tax qualified policies): Walking or otherwise moving independently from one place to another.
Not all long-term care needs are physical. Many policyholders require supervision and support due to mental decline. Severe cognitive impairment is an independent qualifying condition under most LTCI policies. However, unlike a physical impairment, severe cognitive impairment might be assessed using a Chronically Ill Certification (CIC) from a licensed healthcare provider.
California’s Legal Protections for LTC Policyholders
California has some of the most comprehensive long-term care insurance regulations in the country. The California Department of Insurance (CDI) mandates consumer-friendly rules on policy language, premium increases, and claims processing. Here are key protections you should know about:
- Grace Periods for Missed Payments: Policies must offer a 30-day grace period and provide written notice before termination.
- Assessment Rights: You may request independent evaluations or second opinions if the insurer disputes your eligibility.
- Notice and Explanation Requirements: Denials must include specific reasons and reference policy language.
- Benefit Triggers Must Be Clear: Insurers must clearly explain how benefits are triggered and cannot impose vague standards after the fact.
Despite these protections, policyholders still face denials because insurance companies assume most people will not challenge them, or do not know how
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.
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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.
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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.
I Sure Picked The Right Firm!
“In 2020 I was dealing with a Long-Term Disability (LTD) appeal issue with my private LTD provider. After exhausting ‘in house’ appeal methods to no avail, I decided I needed to seek professional legal to assist me with my appeal. Erin and her staff allowed me to work hand-in-hand with them to provide comments on insurance documents provided by my LTD provider. This allowed me to stay actively involved in my case and to assist in providing responses to the provider. Erin and her staff were very knowledgeable, professional, and courteous all the way to our settlement. We settled out of court in the summer of 2021. I highly recommend Ronstadt Law for anyone who has need for legal counsel pertaining to disability issues.
- Ray Ortega | July 2021