Nationwide Long-Term Care Insurance Claims Lawyer
Nationwide offers long-term care benefits through several types of insurance products designed to help policyholders pay for care when illness, cognitive impairment, or loss of physical function makes independent living difficult. When a Nationwide long-term care insurance claim is delayed, disputed, or denied, however, policyholders and their families may suddenly find themselves responsible for substantial care expenses.
At Pillsbury & Coleman, LLP, our long-term care insurance attorneys represent California policyholders in disputes with insurance companies. We examine the policy, medical evidence, claim history, and insurer’s handling of the claim to determine whether benefits have been improperly withheld.
Nationwide Long-Term Care Insurance Coverage
Nationwide’s long-term care offerings include products such as CareMatters®, which combines life insurance with long-term care benefits, as well as other linked-benefit products. Typically, these policies issued by Nationwide contain an “Accelerated Benefit Rider for Health Care,” which obligates Nationwide, among other things, to pay a monthly sum in the event its insured suffers a Qualified Long Term Care Illness.
According to Nationwide’s long-term care claims information, an insured may qualify for LTC benefits when a licensed health care practitioner certifies that the insured:
- Cannot perform at least two activities of daily living (ADLs) without substantial assistance because of a loss of functional capacity expected to last at least 90 days; or
- Has a severe cognitive impairment requiring substantial supervision to protect the insured’s health and safety.
The six ADLs identified by Nationwide are bathing, continence, dressing, eating, toileting, and transferring.
Coverage ultimately depends on the specific policy or certificate. Older policies, newer linked-benefit policies, riders, and other Nationwide products may contain different definitions, limitations, benefit amounts, and requirements.
What Happens When You File a Nationwide LTC Claim?
Filing a claim generally requires more than showing that an insured has been diagnosed with a serious medical condition.
The insurer may evaluate medical records, statements from health care providers, information concerning the insured’s daily functioning, care plans, and other documentation. The central question is often whether the policyholder satisfies the policy’s contractual definition for receiving benefits.
Nationwide states that its current LTC claims process includes a 90-calendar-day elimination period. Once the applicable requirements have been met and a claim is approved, Nationwide says its current products pay a cash indemnity benefit rather than requiring policyholders to continually submit individual bills and receipts.
Because policies vary, policyholders should review their actual policy rather than assume that the requirements described for a current Nationwide product apply to older coverage.
Why Might Nationwide Deny a Long-Term Care Insurance Claim?
Long-term care claims can involve disagreements about both medical evidence and policy language. An insurer may contend that the evidence does not establish that the insured meets the policy’s benefit trigger.
Disputes may involve:
- Whether the policyholder needs sufficient assistance with two or more ADLs
- Whether cognitive impairment is severe enough to qualify
- Whether the elimination or waiting period has been satisfied
- Whether the care being received is covered by the policy
- Whether medical documentation adequately supports the claim
- Whether a particular caregiver or care arrangement qualifies
- Whether benefits remain available under the policy
- Requests for additional examinations, records, or proof of continued eligibility
A denial does not necessarily mean the insurer’s interpretation is correct. Policy language, medical documentation, and the manner in which the claim was investigated can all matter.
Cognitive Impairment and Nationwide LTC Claims
Not every long-term care claim involves a person who is physically incapable of bathing, dressing, or eating.
Dementia, Alzheimer’s disease, and other forms of cognitive decline can create a need for substantial supervision even when an individual retains significant physical ability. Nationwide identifies severe cognitive impairment requiring substantial supervision as a separate potential benefit trigger from an inability to perform ADLs.
This distinction can be particularly important when a claim involves memory loss, confusion, wandering, medication management, or other safety concerns.
Families should document changes in cognitive function and supervision needs and work with treating medical professionals to ensure the insurer receives an accurate picture of the policyholder’s condition.
What Should I Do If Nationwide Denies My LTC Claim?
Start by obtaining the written denial and identifying the specific policy provisions Nationwide relied upon. You should also retain copies of medical records, care assessments, correspondence with Nationwide, claim forms, and other documents submitted during the claim.
The California Department of Insurance provides long-term care insurance information and resources for consumers, including information concerning LTC insurers and assistance with insurance complaints.
Before submitting a lengthy response or appeal, it may also be useful to have the policy and denial reviewed by an attorney familiar with insurance bad faith claims. What happens during the claim and appeal process can affect a later dispute over benefits.
How Pillsbury & Coleman Can Help With a Nationwide LTC Claim
Pillsbury & Coleman represents policyholders rather than insurance companies. Our attorneys handle disputes involving long-term care, disability, life, and other insurance benefits.
In a disputed Nationwide long-term care claim, our review may include the policy’s benefit triggers, elimination period, medical evidence, claim correspondence, care requirements, and the insurer’s stated reasons for withholding benefits.
When an insurer fails to honor its contractual obligations, California law may provide remedies beyond simply requesting that the carrier reconsider its decision. The appropriate options depend on the facts of the individual claim.
Learn more about our firm’s experience handling insurance claims or contact Pillsbury & Coleman to discuss a Nationwide long-term care insurance dispute.
Our Experience With Long-Term Care Insurance Denials
Pillsbury & Coleman has represented long-term care policyholders and their families in disputes involving repeated benefit terminations, cognitive impairment claims, and insurer bad faith.
The following result illustrates the firm’s experience litigating a long-term care claim in which the insurer disputed whether a policyholder’s cognitive impairment was severe enough to qualify for benefits.
Case Result — Turley v. Prudential Insurance Company
Confidential Settlement | Nationwide Life and Annuity Insurance Company
- Defendants: Nationwide
- Claimant: An elderly insured diagnosed with Parkinson’s Disease, lumbar disc disease, and dementia86-year-old
- Qualified Long Term Care Illness: A documented history need for long-term care assistance in order to assist with the performance of Activities of Daily Living and supervision in order to protect against threats to safety, including standby assistance for bathing, dressing and fall prevention, and overall supervision and oversight.
- Disputed Conduct: After paying benefits for five years, the insurer terminated benefits, claiming that the need for care had been exaggerated.
- Result: Pillsbury & Coleman filed a bad faith lawsuit and obtained a settlement for a confidential amount.
- Court: San Francisco County Superior Court, Case No. CGC-2605387.
Frequently Asked Questions About Nationwide Long-Term Care Claims
What are the six activities of daily living used by Nationwide?
Nationwide identifies bathing, continence, dressing, eating, toileting, and transferring as the six ADLs used in its current LTC benefit eligibility criteria.
Does dementia qualify for Nationwide long-term care benefits?
It can. Nationwide recognizes severe cognitive impairment requiring substantial supervision as a potential benefit trigger. A policyholder therefore does not necessarily need to be physically incapable of performing two ADLs to qualify. Eligibility depends on the policy language and evidence supporting the claim.
Does Nationwide have an elimination period for long-term care benefits?
Nationwide states that its current LTC claims process includes a 90-calendar-day elimination period. Requirements can differ by policy, however, so an insured should check the actual contract governing the claim.
Can I challenge a Nationwide long-term care insurance denial?
Yes. A policyholder may be able to challenge a denial by addressing the insurer's stated reasons and supplying additional medical or other evidence. When substantial benefits are at stake, an attorney can review whether the denial is consistent with the policy and California insurance law.
When should I contact an attorney about a Nationwide LTC claim?
Consider seeking legal advice when benefits have been denied, terminated, substantially delayed, or repeatedly subjected to requests for additional information. An attorney can review the policy and claim record before determining what options may be available.
Speak With a California Long-Term Care Insurance Attorney
Long-term care insurance is often purchased to provide financial protection at precisely the point when a policyholder becomes most vulnerable. A dispute over benefits can place additional pressure on both the insured and the family members arranging care.
If Nationwide has denied, delayed, or terminated long-term care insurance benefits, contact Pillsbury & Coleman, LLP to discuss the claim with an experienced California insurance attorney.