Long-Term Care Group (LTCG)  Claim Denials

Long-Term Care Group (LTCG) plays a central, yet often misunderstood, role in the long-term care (LTC) insurance industry. While you may have purchased your policy from a well-known insurer, it is possible that LTCG is the entity actually administering and managing your claim.

LTCG functions as a third-party administrator (TPA), handling the day-to-day operations of LTC policies for numerous major insurance carriers. This means that when you file a claim, it is often LTCG’s processes, interpretations, and procedures that directly impact whether your benefits are approved or denied.

At Sandstone Law Group, we understand the immense frustration and distress that arises when policyholders, who have diligently paid premiums for years, are met with delays, confusing communications, or outright denials from claims administrators like LTCG.

We are committed to providing clear, empathetic, and legally credible guidance, standing firm and even aggressive against claims handlers and insurance companies who fail to honor their commitments.

LTCG's Long-Term Care Insurance History

LTCG (now operating under Illumifin) is one of the largest third-party administrators specializing in long-term care insurance. They do not issue policies themselves but are contracted by major insurance companies to handle the entire lifecycle of an LTC policy, from customer service and premium collection to, most importantly, claims intake, processing, and benefit determination. This includes:

• Initial Claim Intake: Receiving your application for benefits and all supporting documentation.
• Eligibility Assessment: Reviewing medical records, physician statements, and functional assessments to determine if you meet the policy's benefit triggers (e.g., ADLs or cognitive impairment).
• Care Plan Review: Evaluating your proposed care plan, whether for home care, assisted living, or nursing home facilities, against policy terms and often their own internal guidelines.
• Provider Verification: Scrutinizing the qualifications and licensing of your chosen care providers or facilities.
• Ongoing Claim Management: Monitoring your continued eligibility, requesting updated documentation, and processing reimbursement payments.

LTCG collaborates with several major insurance carriers, providing third-party administration services. Notably:

• Transamerica: In 2019, Transamerica entered into an agreement with LTCG to transfer the administration and claims management of its LTC insurance business, encompassing new business, policyholder service, claims processing, and care management.
• CNA Insurance: CNA's group long-term care insurance policies are administered by illumifin, the parent company of LTCG

Additionally, LTCG has been involved in administering the CalPERS self-funded LTC insurance program since its inception in 1995, providing a full suite of professional, administrative, and care management services.

Implications for Legal Disputes and LTCG's Legal History

LTCG has been involved in notable legal cases related to long-term care insurance. These instances shed light on the challenges policyholders may face and underscore the importance of vigilant legal advocacy.

·         Wedding v. CalPERS (Class Action Settlement): LTCG served as the third-party administrator for the California Public Employees' Retirement System (CalPERS) Long-Term Care Program. In this role, LTCG was implicated in a class-action lawsuit alleging that CalPERS improperly raised long-term care insurance premiums by 85% in 2012, despite prior promises of rate stability. The lawsuit culminated in a settlement, which was finalized on September 28, 2023. This settlement allowed policyholders to choose between a refund of 80% of premiums paid or continued coverage with adjusted terms.

·         Transamerica and LTCG: Denial of Benefits to Same-Sex Couple: In 2022, a lawsuit was filed against Transamerica and LTCG. The suit alleged that these entities denied long-term care benefits to an elderly woman by misclassifying her same-sex partner as an ineligible caregiver. The lawsuit claimed negligence on the part of LTCG in evaluating the claim. Notably, the denial was reversed on the same day the lawsuit was filed, which raised questions about the initial claims processing.

Understanding Long-Term Care Claims

Long-term care insurance policies typically stipulate that policyholders must satisfy one of two primary criteria to be certified as Chronically Ill or Disabled and thus eligible for benefits:

• The individual must demonstrate a loss of the ability to perform, without Substantial Assistance, at least two Activities of Daily Living (ADLs).
• The individual must possess a severe cognitive impairment, which necessitates Substantial Supervision to safeguard them from threats to their health or safety.

The six common ADLs are:

• Bathing: The act of washing oneself by sponge bath, or in either a tub or shower, including the critical task of safely getting into or out of the tub or shower.
• Dressing: The ability to put on and take off all items of clothing and any necessary braces, fasteners, or artificial limbs.
• Eating: The act of feeding oneself by getting food into the body from a receptacle (such as a plate, cup, or table) or through specialized means like a feeding tube or intravenously.
• Transferring: Sufficient mobility to move safely into or out of a bed, chair, or wheelchair, or to move from place to place, whether by walking, using a wheelchair, or by other assistive means.
• Toileting: The ability to get to and from the toilet, to get on and off the toilet, and to perform associated personal hygiene.
• Continence: The capacity to maintain control of bowel and bladder function, or, when unable to maintain control, the ability to perform associated personal hygiene (including the care of a catheter or colostomy bag).

If a person requires “substantial assistance” in two or more of these specified areas, they may qualify for benefits under their long-term care insurance policy. “Substantial assistance” can encompass either hands-on assistance or standby assistance, depending upon the precise wording of the policy.

If an individual is cognitively impaired and requires oversight that may include cueing through verbal prompting, gestures, or other demonstrations by another person, and such supervision is demonstrably necessary to protect them from threats to their health or safety, they may also qualify for benefits under an LTC insurance policy.

Why LTCG Denials Are a Unique Challenge

While LTCG is an administrator, its approach to claims handling can often mirror the cost-conscious strategies of the insurers it represents. When your claim is processed by LTCG, you may encounter specific challenges that make securing benefits particularly difficult:

1. Excessive and Repetitive Documentation Demands: LTCG can send voluminous requests for information. They may ask for documents you have already submitted, or demand highly granular details about your care and functional limitations. This "death by paperwork" tactic is designed to create confusion, induce delays, and exhaust policyholders and their families, hoping they will give up.
2. Rigorous Review of Functional Triggers: Even though LTC is based on functional impairment, LTCG may employ stringent interpretations of ADL definitions. They might dispute the level of assistance you require, send their own nurse to assess your abilities (who may not specialize in your specific condition), or claim that your treating physician's certification is insufficient.
3. Strict Interpretation of Care Provider Qualifications: LTCG rigorously enforces policy clauses regarding who can provide covered care. They may deny claims if a caregiver is not formally licensed, if a facility is not on an "approved list," or if the services provided are deemed not to meet the policy's specific definitions (e.g., distinguishing between "custodial" and "skilled" care).
4. Reliance on Internal Reviewers and Independent Medical Exams (IMEs): LTCG, like many claims administrators, may rely on internal medical professionals or contracted third-party physicians to review your medical records. These reviewers may issue opinions that contradict your treating physician's assessment, often without personally examining you, leading to denials.
5. Systemic Delays and Communication Issues: Due to the sheer volume of claims they handle, LTCG can be prone to administrative backlogs. Communication can be slow, inconsistent, or confusing, leaving policyholders uncertain about the status of their claim or what further steps they need to take. These delays often create significant financial strain, especially during the elimination period.

Common Reasons LTCG Denies Claim

LTCG's claim denials often fall into several predictable categories, stemming from the aforementioned tactics:

• Failure to Meet Eligibility Requirements: This is a primary reason, where LTCG concludes you do not meet the minimum number of ADL triggers or the severity of cognitive impairment required by your policy. They may dispute the functional necessity of your care.
• Documentation and Paperwork Issues: Denials frequently occur due to allegedly "incomplete or missing paperwork," or because daily care logs are deemed insufficient or inconsistent.
• Provider Qualification Problems: Your claim may be denied because your care provider or facility does not meet LTCG's strict interpretation of policy requirements for licensing, certification, or "approved" status.
• Elimination Period Not Satisfied: Denials can occur if LTCG determines that the elimination period was not fully satisfied according to their specific counting rules (e.g., due to breaks in care, using unqualified providers, or differing interpretations of "days of service").
• Policy Exclusions or Limitations: Although less common in the practice space for pre-existing conditions, other policy exclusions (e.g., specific types of care not covered, territorial limitations) can be cited.

Why Sandstone Law Group is Your Advocate Against LTCG

Fighting a claims administrator like LTCG can feel like an overwhelming task. They are a large, experienced entity representing the financial interests of major insurers. You do not have to navigate this process alone. While an appeals process may be offered, whether to pursue an internal appeal or immediate legal action is a case-specific consideration that demands legal advice.

Sandstone Law Group focuses on challenging long-term care denials, including those handled by LTCG. We are committed to:

• Aggressive Advocacy: We stand firm and aggressive against claims administrators and insurance companies that fail to honor their commitments. Our goal is to ensure you receive the benefits you are owed.
• Building a Robust Case: We meticulously review your policy, gather compelling medical records and financial documentation, and build a strong argument that directly counters LTCG's denial reasons. We emphasize the "functional necessity" of your care as defined by your policy.
• Strategic Legal Counsel: We provide clear guidance on the best path forward, whether that involves preparing a detailed administrative appeal or pursuing litigation when necessary. We ensure your rights are protected and that all procedural requirements are met.
• Holding Insurers Accountable: We represent policyholders who purchased LTC plans years ago and are now finding that companies are "not honoring them". We are dedicated to fighting for justice and ensuring accountability for delayed or denied benefits.

Contact Sandstone Law Group Today

If your long-term care claim administered by LTCG has been wrongfully denied, or you are experiencing frustrating delays and confusing communications, it is time to seek legal guidance. Such actions by claims administrators and insurers are not merely administrative hurdles; they are a profound betrayal of the financial security you carefully planned for.

At Sandstone Law Group, we are not intimidated by large administrators like LTCG or the complex legal challenges they present. We understand their tactics, from overwhelming you with paperwork to misinterpreting policy terms or disputing your functional needs. We take on cases that others may shy away from, prepared to fight relentlessly to hold these companies accountable when they fail to honor the long-term care plans you purchased years ago.

If you are facing an LTCG claim denial or are struggling with delays and endless paperwork, do not concede your rightful benefits. The time to act is now.

Contact us today at (602) 615-0050 to schedule a consultation. Let us uncover the truth, enforce your rights, and make sure your insurer delivers the protection they promised.