Long Term Care Insurance

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Long term care insurance (LTC) is an insurance product sold by large life insurance companies in Canada that usually provides a monthly payment or reimbursement of expenses if you become unable to care for yourself and need assistance to manage your daily activities.

Most policies require you to be incapable of performing two or more activities of daily living without assistance, such as bathing, dressing or eating.

If you or a loved one have made a claim and the claim has been denied, it is important to understand your rights and whether you can challenge this decision.

Misrepresentation of Pre-Existing Health on Application

One reason a claim for Long Term Care Insurance may be denied has to do with how the insurance was purchased. During the application process you will be required to provide answers to questions about your health so that the insurance company can decide whether to sell you this type of policy. If a claim is made, the insurance company will scrutinize the answers given during the application process and if there were any inconsistencies or incorrect answers, this may form the basis for the claim to be denied. This type of denial will usually say that if the insurance company had accurate answers at the time of the application, they would not have issued the policy in the first place.

Here is an example of how this denial may arise:

A 55-year-old man took out LTC insurance and the underwriting application included the following question:

"Do you currently have, or have you ever been diagnosed with, or ever been treated for, any of the following conditions:"

(the list conditions included the following):

• Multiple Sclerosis
• Muscular Dystrophy
• Parkinson’s Disease

He answered no to this question as at the time of application no diagnosis of any of these conditions had been made, however, a few years before buying the policy he had been seen by a neurologist to investigate some symptoms that may have been Multiple Sclerosis. At the time, no such diagnosis was made, despite the symptoms.

After the policy was issued, the man had a resurgence of symptoms and had additional symptoms that ultimately led to a diagnosis of MS and his illness had progressed to the point that he required assistance with several of his activities of daily living.

His claim for LTC Insurance was denied on the basis that he had consulted a doctor and received some treatment for MS in the past, even though it had not been diagnosed at the time.

In a case like this, it may be possible to challenge the denial as the decision appeared to be a question of interpretation and opinion regarding what his prior medical records disclosed. It may be possible to still recover all or part of the funds owed through legal action.

When buying long term care insurance make sure you provide accurate answers to any questions about your prior health to try to ensure that you won’t experience a claim denial when a long term care claim has to be made. If your claim is denied, contact our team of long term care lawyers to see how we can help you.

Does Not Require Assistance with at least 2 Activities of Daily Living (ADLs)

A 77-year-old woman suffering from a number of health conditions. Her ADLs were impacted and in order to qualify for payments under her LTC policy 2 of the following ADLs would require assistance:

• Bathing
• Dressing
• Eating
• Mobility
• Transferring
• Toileting
• Continence
• Cognitive Impairment

She did require some assistance with mobility and also suffered some cognitive impairment. Her family believed that the long term care policy should be paying her and a claim was submitted. The long term care claim was denied on the basis that while she had some mobility and transferring issues, she was able to handle these some of the time, and furthermore, while she had some cognitive issues, the insurance company didn’t believe it was so severe that she could not care for herself.

She was mostly still able to do the remaining ADLs.

The question of whether she qualified was debatable, however, there was sufficient ambiguity to look into the matter further.

By taking legal action, her family was able to recover funds from the insurance company on a compromised basis that provided assistance in paying the cost of extra assistance that improved her quality of life.

We Can Help

Before accepting a refusal by an insurance company to pay out on a long term care insurance policy, we encourage you to consult further with our insurance lawyers for long term care insurance claims to determine whether we can assist you to challenge your insurance denial. The reason insurance companies deny claims for disability benefits and long term care insurance benefits is because the individual does not require personal care of other services described in the fine print of the policy. Most of these insurance law claims are initiated by a family member so that retirement savings are not entirely depleted.