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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.
How we can support you
After being denied your long term care insurance benefits, you might not know where to turn next. You may feel hopeless in this moment, but rest assured you are not alone. When you call Share Lawyers, you will speak with someone who knows what you are going through and can offer you the best possible advice at no cost to you.
Why you should contact us:
- It’s free to talk to us
- There are no fees unless you win
- We specialize in LTC claims and can go through your options
- We can make arrangements for a free consultation with one of our LTC lawyers to see how we can help you get your long term care benefits
- We are there to answer all of your questions
Why was my long term care insurance claim denied?
Misrepresentation of Pre-Existing Health on Application
One reason a claim for Long Term Care Insurance may been 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:
- 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 lawyers for long term care insurance claims to determine whether we can assist you to challenge the decision to deny the claim.
How much time do I have?
There are time limits to all disability claims and any delay in proceeding may be subject to a deadline so you should not delay in proceeding with your disability claim or obtaining legal advice to clarify these deadlines. We understand how important these timelines are and will respond to any call or email as soon as we can.
Disability Lawyers in Toronto, proudly serving clients in Ontario and across Canada
Are you looking for a disability lawyer to fight for your rights? Our law firm have unmatched experience in disability law and we don't let provincial borders stop us from helping you in your time of need. Your insurance company has a presence throughout Canada and it makes sense to hire a disability law firm that has a true expertise in disability law and has a national presence too. Your insurance company knows who we are and knows that we won’t back down.
Regardless of whether you have just applied for your insurance benefits or have been denied your benefits by your insurance company and need support, we will talk you through all of your options — free of charge. It’s important to be informed about the insurance claim process and to know your rights.
No fees unless you win your case
We understand your situation and that paying for an insurance lawyer can feel out of reach. We are here to help you no matter where you are in the process. That is why we offer a free consultation, why there are no upfront costs to you, and why there are no fees unless you win your case. You’re not alone. We believe in your case, which is why we only get paid when you do.
When you work with us, you get guidance and tools to help you along the way. You will become a member of a privileged group of clients that have access to our hub, called Life reBUILDER™, exclusively from Share Lawyers. It offers six unique services to help rebuild your life and get you back on track, beginning with the expertise of a full legal team all working for you.