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

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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

Answers:

SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 3 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.


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