Unum Long-Term Care Insurance Denials

When you or your loved one made the prudent decision to invest in a Unum long-term care insurance (LTC or LTCI) policy, often many years or even decades ago, you were not simply purchasing a financial product. You were securing a commitment to support during one of life’s most vulnerable and challenging chapters.

At Sandstone Law Group, we possess a deep understanding of the unique challenges faced by Unum policyholders today. These challenges arise not only from the insurer’s current claims handling practices but also from the extensive history and the aging framework of these long-discontinued long-term care products.

We are dedicated to representing individuals and families who have been wrongfully denied long-term care benefits by Unum. If Unum has denied or delayed your long-term care claim, we are here to challenge that decision with unwavering resolve and to secure the care and coverage you were unequivocally promised.

Unum’s History With Long-Term Care Insurance and Its Implications

Though Unum’s reputation is often associated with its significant presence in the disability market, its involvement in the long-term care sector, though perhaps less prominent today, has left a legacy of policies that continue to impact countless lives.

Unum, like other major insurers, entered the long-term care market in response to a growing societal need for coverage against the costs of extended care. Policyholders purchased these plans with the expectation that a financially robust company like Unum would honor its commitments when the time came to utilize the benefits.

While Unum’s LTC denials and misconduct have been less documented, this is likely to change, and Unum is already seeing an increase in scrutiny for its long-term care insurance practices: 

• In 2016, Unum agreed to a $46 million settlement in a class action lawsuit filed in California. The lawsuit alleged that Unum miscalculated annual inflation increases and improperly set policy anniversary dates, resulting in policyholders being denied the full benefits of their LTC policies. This settlement addressed systemic issues in Unum's LTC benefit calculations.
• In a new agreement with Maine insurance regulators, Unum Group committed to increasing its statutory long-term care insurance reserves by $2.1 billion over seven years. 
• In Maramonte v. Unum Group, the plaintiff alleged that Unum acted in bad faith by refusing to honor the terms of the LTC policy, leading to a lawsuit seeking the owed benefits and additional damages. Mrs. Maramonte, an 86-year-old woman, suffered from a range of debilitating health conditions, including major neurocognitive disorder (dementia), colon cancer, severe depression, and malnutrition. She frequently became disoriented, required supervision for her safety, and was at high risk for falling. Like many aging Americans, she had wisely purchased a long-term care insurance policy designed to provide financial support if she ever needed help with activities of daily living. Despite the clear medical need for care, her insurance provider, Unum, denied her claim for long-term care benefits. The case underscores concern about Unum's claim handling practices in the LTC insurance sector.

Understanding Long-Term Care Insurance

The fundamental purpose of LTCI is to provide financial support for services when a chronic illness, a severe cognitive impairment, or a disabling condition renders it difficult or impossible for an individual to live independently.

Unum long-term care insurance policies, consistent with the industry standard, 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.

ADLs are generally standardized benchmarks utilized to determine eligibility for long-term care benefits. However, even these seemingly clear definitions can be fraught with potential ambiguity regarding what precisely constitutes an ADL. Common definitions typically include the following:

• 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 they require 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.

Common Tactics Unum Uses to Deny Long-Term Care Claims

The claims process with Unum can sometimes involve procedures that many policyholders find challenging, stressful, and difficult to navigate:

1. Denying Care Based on Allegedly “Mild” Impairments

Unum may assert that you do not qualify for benefits because your cognitive impairment or ADL limitations are deemed “not severe enough.” Often, these assessments are predicated upon brief, arguably biased evaluations that conspicuously ignore critical daily safety concerns and disregard the well-considered recommendations of treating physicians who possess a comprehensive understanding of the policyholder’s condition.

2. Canceling Coverage Due to Lapses or Premium Errors

If a policyholder inadvertently misses a payment, whether this oversight is attributable to the onset of cognitive decline, an administrative mistake, or even errors in mail delivery, Unum may proceed to cancel the policy without providing the legally required notice. Subsequently, the insurer may steadfastly refuse to reinstate coverage, even when the urgent need for care is undeniable and immediate.

3. Rejecting Claims Based on Restrictive Care Provider Definitions

Unum might deny coverage by contending that your caregiver is not properly licensed or does not meet an overly narrow interpretation of policy terms, even when the care being provided is professional, medically appropriate, and demonstrably necessary. This rigid reading of policy terms is frequently employed to withhold benefits based on technicalities rather than genuine disputes concerning the quality or necessity of the care.

4. Delays, Red Tape, and Opaque Communications

From incessant and often redundant requests for documentation to abrupt and unexplained policy reinterpretations, Unum’s claims process is frequently structured to exhaust and wear down claimants. Many families, overwhelmed by the protracted delays and bureaucratic hurdles, reluctantly give up or are forced to pay out-of-pocket for essential care while awaiting a decision—a scenario that, unfortunately, appears to be precisely what the insurer hopes to achieve.

5. Utilizing Internal Fraud Units Without Clear Standards or Training

Insurance companies, including Unum, commonly operate internal fraud investigation units. In many cases, these units operate arguably without transparent written procedures, adequate training for investigators, or proper oversight. Investigators may proceed with inquiries without fully comprehending the nuances of the policy terms, without proactively seeking exculpatory evidence that could support the claim, and without ensuring that their actions consistently comply with established fair claims practices.

6. Incentivizing Claim Terminations Through Strategic Initiatives

As part of a broader corporate strategy to manage financial exposure stemming from older long-term care policies, insurance companies like Unum may implement departments or initiatives, such as a “Fraud, Waste, and Abuse” unit, that track and arguably reward claim terminations. In some companies, internal performance evaluations for staff involved in these units have placed undue emphasis on metrics such as the number of fraud referrals generated and the total “impact” measured in dollars saved from terminated claims. This environment can inadvertently or deliberately create immense pressure to prioritize cost-cutting objectives over an objective, impartial, and fair evaluation of a legitimate claim.

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

Investigative efforts undertaken by Unum may appear to concentrate exclusively on gathering evidence that supports a denial, while simultaneously downplaying or entirely excluding information that could unequivocally support the claim. In certain instances, surveillance is utilized without disclosure to the claimant during the appeal process, and crucial exculpatory evidence may be conspicuously omitted from investigative reports.

8. Continuing to Collect Premiums Even After Alleging Fraud

Perhaps one of the most concerning tactics is the practice, observed in some cases with insurance companies like Unum, of continuing to collect monthly premiums from policyholders even after claims have been denied and cases have been referred to state insurance departments for alleged fraud. This profound inconsistency raises serious questions about the insurer’s internal decision-making processes and whether fraud allegations are being applied appropriately and in accordance with established industry standards.

Appealing a Unum Long-Term Care Claim Denial

When your LTC claim is denied by Unum, your immediate instinct might be to file an appeal. However, with some long-term care policies, filing an internal appeal is not always a legal requirement, nor is it always the most advantageous path forward.

To further complicate matters, long-term care policies exhibit wide variations. Some policies may include optional or informal appeal procedures, while others might stipulate that you must submit an appeal within a specific timeframe, such as 180 days. Crucially, many long-term care policies do not mandate an internal appeal whatsoever before legal action can be pursued.

Knowing whether to appeal, precisely when to appeal, and how to meticulously craft a persuasive and legally sound appeal requires a detailed and nuanced understanding of your specific policy terms, the governing state law, and the insurer’s historical claims-handling practices. This is unequivocally a case-by-case consideration, demanding expert analysis.

Do not assume you are obligated to appeal, and you should absolutely not risk submitting an appeal without first obtaining qualified legal counsel. If your Unum long-term care claim has been denied, allow our experienced team at Sandstone Law Group to meticulously review your policy, comprehensively explain all of your available options, and assist you in choosing the most effective path forward.

Why Choose Sandstone Law Group?

At Sandstone Law Group, our fundamental mission is to fight tirelessly to restore dignity, ensure safety, and re-establish financial security for individuals and families who have been wrongfully denied long-term care benefits.

Long-term care insurance is intended to provide essential support precisely when it is needed most, not to create additional burdens or financial distress. Yet, far too frequently, Unum and other major insurers appear to deliberately delay, systematically underpay, or outright deny valid claims.

• We Listen First: You will encounter attorneys who listen with genuine compassion and absolute clarity. Attorneys Kyle Shelton and Erin Ronstadt will never rush through your story or treat you as merely a file number. We intentionally create a supportive space for you to be heard, and from that foundational place of understanding, we meticulously construct a legal strategy that accurately reflects the full truth of your condition, your specific care needs, and your indisputable policy rights.
•  We Know Unum’s Playbook: Our team possesses extensive and proven experience confronting Unum and other major insurers regarding long-term care denials. We understand the exact tactics they employ to avoid payment: what we perceive as biased assessments, deliberately vague denials, and self-serving, incorrect policy interpretations. More importantly, we know precisely how to systematically dismantle these tactics. Whether the issue involves disputed ADL limitations, complex cognitive impairment claims, policy lapses, or coverage gaps, we are thoroughly prepared to fight back with aggression and precision.
• We Are Built for Litigation: We prepare every single case as if it will proceed to court. This steadfast reputation for litigation readiness compels insurers to treat our clients with the seriousness and respect they rightfully deserve. And when trial becomes necessary to secure justice, we possess the comprehensive litigation experience and a proven track record of successful results to see your case through to its rightful conclusion.
•  We Win: Our dedicated attorneys, Kyle Shelton and Erin Ronstadt, have consistently secured life-changing results for clients who faced financial ruin and immense emotional distress after a denied claim. Whether through aggressive negotiation or through decisive action in court, we will not cease our efforts until we have exhausted every possible avenue to ensure our clients receive the care and coverage they were promised.

How Sandstone Law Group Can Help

Challenging a Unum LTC claim denial requires aggressive, strategic, and highly experienced legal representation. At Sandstone Law Group, our unwavering commitment is to fight relentlessly for the benefits you have paid for and rightfully deserve.

Here is how our dedicated team can provide essential assistance:

• Thorough Case Evaluation: We meticulously review all relevant documents pertaining to your claim, including your Unum policy, all pertinent medical records, and the official denial letter. This comprehensive assessment enables us to precisely identify any discrepancies, errors, or missing information that may have contributed to the denial, as well as to pinpoint critical opportunities to significantly strengthen your case.
• Aggressive Advocacy and Negotiation: We are widely recognized for our firm and unyielding advocacy on behalf of our clients. We actively engage with insurance companies to challenge unfair practices and tirelessly pursue the benefits to which you are legally entitled. While we always strive for a fair and equitable resolution through negotiation, we are fully prepared to litigate if such action becomes necessary to comprehensively protect your rights.
• Litigation Experience: Our experienced litigators are exceptionally well-versed in the complexities of insurance litigation and approach each case with unwavering tenacity. We leverage our extensive courtroom experience to present a compelling and irrefutable case, advocating vigorously for your rights within a legal setting. Kyle and Erin possess substantial courtroom and trial experience and are prepared to take your case as far as it needs to go to achieve justice.

Contact Sandstone Law Group Today

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

At Sandstone Law Group, we profoundly understand that every single day without the necessary care puts your health, your independence, and your financial stability at severe risk. Our dedicated team will not only fight relentlessly to reverse a wrongful denial, but we will also meticulously build a comprehensive strategy to hold Unum fully accountable for the entire value of what they owe you.

Whether through aggressive negotiation or through decisive courtroom litigation, we are absolutely relentless in our pursuit of justice for policyholders who have been mistreated. Allow us to help you reclaim control over your future and your care.

Contact us today at (602) 615-0050 to schedule a confidential consultation. Let us make certain that Unum honors its promises, because your essential care should never be contingent upon corporate convenience or profitability.