What can be done if a long term care provider refuses to pay a claim?

UPDATED: Oct 1, 2022

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What can be done if a long term care provider refuses to pay a claim?

My mother bought a LTC policy 15 years ago. She now has Alzheimer’s

and I am her daughter and POA. The insurance company will not pay claims for my mother’s caregiver because she also happens to be her niece. The policy does not state that a family member cannot be a caregiver, it explains what a family member is but does not mention that a niece is a family member. This policy actually has a family indemnity rider which provides payment for family members at 50% of the maximum benefit for 1 year, however it does not

mention a niece. The company is stating that their reasoning is a clause in the

exclusions that reads says they will not pay for

Asked on June 11, 2018 under Insurance Law, Georgia


SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 4 years ago | Contributor

You can sue the insurer for "breach of contract" if you believe, as you evidently do, that they should be paying but are not--that is, that they are violating the terms of the policy. An insurance policy is a contract; the insurer has to pay when the terms of the policy require it to. As with any other contract, the policy can be enforced in court: if the other party (the insurer) will not honor its obligations or pay what it should, you can sue them for the money they should have paid and/or for a court order that they pay going forward. Consult with an attorney with experience suing insurance companies to explore this option.

IMPORTANT NOTICE: The Answer(s) provided above are for general information only. The attorney providing the answer was not serving as the attorney for the person submitting the question or in any attorney-client relationship with such person. Laws may vary from state to state, and sometimes change. Tiny variations in the facts, or a fact not set forth in a question, often can change a legal outcome or an attorney's conclusion. Although AttorneyPages.com has verified the attorney was admitted to practice law in at least one jurisdiction, he or she may not be authorized to practice law in the jurisdiction referred to in the question, nor is he or she necessarily experienced in the area of the law involved. Unlike the information in the Answer(s) above, upon which you should NOT rely, for personal advice you can rely upon we suggest you retain an attorney to represent you.

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