Long-Term Care Insurance Denials for Alzheimer’s and Dementia
Alzheimer’s and dementia are progressive, degenerative brain disorders that eventually rob individuals of the ability to care for themselves. As the diseases advance, most patients will require long-term care services, ranging from in-home assistance to full-time memory care facilities. While many individuals purchase long-term care (LTC) insurance for this reason, denials are common. If your claim has been denied or delayed, legal intervention from a long term care insurance lawyer in Arizona may be necessary to secure the benefits you’ve paid for.
What is Alzheimers and Dementia?
Many people think of Alzheimer’s when they think of dementia, and while it is under that umbrella, there are many types of dementia. The Alzheimer’s Association estimates that California and Arizona have nearly 720,000 and 152,000 cases, respectively. The disease is characterized by a buildup of proteins in the brain. These buildups cause nerve cell death, causing a dramatic reduction in the size of the brain and affecting all areas. Due to the extensive and progressive damage of Alzheimer’s, the disease is ultimately fatal over several years. The Mayo Clinic reports there are five commonly accepted stages of Alzheimer’s. The first two stages are known as the preclinical and mild cognitive impairment stages, where the individual may function relatively normally, and symptoms are not significant enough to detect. The symptoms will often start slow and escalate faster as the disease progresses, meaning you may start considering options for disability in the not-so-distant future once you receive the diagnosis.
Understanding Alzheimer’s and Dementia in the Context of LTC
Alzheimer’s is the most well-known form of dementia, though there are other types, including vascular dementia, Lewy body dementia, and those related to Parkinson’s or other neurological diseases. Regardless of the type, these conditions result in cognitive decline, memory loss, impaired judgment, communication difficulties, and eventually, the inability to perform daily tasks. As the disease progresses, long-term care becomes essential. Most people require:
- Help with basic activities (eating, bathing, dressing)
- Transportation and medication management
- Supervision for safety
- Placement in assisted living or memory care facilities
These services are precisely what long-term care insurance is designed to cover, yet insurers often push back.
Why LTC Claims for Dementia Get Denied
Insurance providers may challenge dementia-related claims for several reasons:
- Claiming the policy doesn’t cover cognitive impairment or only covers physical disabilities
- Disputing the severity of the condition or requiring unnecessary proof that the person needs full-time care
- Citing pre-existing condition clauses if the policyholder had early signs of cognitive decline before the policy went into effect
- Delaying approval by repeatedly requesting the same documentation or conducting unnecessary independent medical evaluations
These are common delay-and-deny tactics. If your loved one is clearly unable to care for themselves, these actions may amount to bad faith.
How to Support a Denied Claim
To strengthen or appeal your claim, you’ll need solid documentation:
- A formal Alzheimer’s or dementia diagnosis from a neurologist or specialist
- Medical records showing progression of the disease
- Physician letters detailing the patient’s inability to perform ADLs (activities of daily living)
- Neuropsychological testing results
- Statements from caregivers or family members on daily care needs
Your policy likely requires evidence that the individual cannot independently perform at least two ADLs or has severe cognitive impairment. Meet those thresholds clearly in your documentation.
Signs of Bad Faith in Long-Term Care Insurance
If your insurer is acting in bad faith, you may see red flags like:
- Unreasonable claim denials despite valid documentation
- Delays with no clear explanation or repeated document requests
- Lowball settlement offers
- Refusal to communicate or failure to respond within a reasonable timeframe (48 hours or more)
Bad faith insurance conduct is illegal. If you suspect this is happening, you may be entitled to sue not only for the benefits owed but for additional damages.
Fight Back Against Wrongful LTC Denials
At Dawson & Rosenthal, P.C., we represent families dealing with long-term care claim denials related to Alzheimer’s and dementia. Our goal is to force insurance companies to uphold their obligations and provide the benefits promised under your policy. If you’re struggling to get coverage for essential care, reach out today for a consultation.