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Why are Alzheimer’s insurance claims denied?

On Behalf of | Aug 1, 2022 | Denied Insurance Claims

An Alzheimer’s diagnosis can be scary. And if you’re taking care of your parent who has been diagnosed with this condition, it can be heartbreaking to watch their physical and cognitive decline.

It can be difficult nowadays to find appropriate care for those who suffer from Alzheimer’s, too, and when care is secured it can be enormously expensive. You might take comfort knowing that your parent has insurance coverage that should help them cover these expenses, but the sad reality is that many Alzheimer’s-related claims are denied.

There could be a number of factors that contribute to a denial of your loved one’s claim. Perhaps the most common is the argument that your parent’s cognitive issues predated his or her physical abilities. This is because most policies restrict your ability to obtain coverage if you have a pre-existing condition, and signs of Alzheimer’s can last for a long time before they lead to interference with daily life. That’s problematic because the long-term care insurance policy won’t kick in until your parent struggles to complete everyday tasks such as bathing, toileting, and eating.

Independent medical examination

Given that your loved one has to prove physical deficits, the insurance company might also claim that your parent’s shortcomings are not as bad as claimed. This is often argued after the results of an independent medical examination are released, which may contradict the opinion of your parent’s doctor.

One way this outcome is achieved through an independent medical examination is by conducting various cognitive screening tests, with certain cutoffs being given to demonstrate an appropriate level of decline to qualify for an insurance payout. However, sometimes these tests fail to take into account other considerations, such as your parent’s education and occupation, which is pretty unfair.

Other reasons for a claim denial may include that the insurer doesn’t find a medical treatment to be medically necessary and that services rendered or prescriptions given were considered “off-label,” meaning that the service or medication in question were not intended to be used for Alzheimer’s treatment.

How your parent can support their Alzheimer’s claim

Although there are a lot of ways that insurance companies can deny an Alzheimer’s-based claim, there are also steps that your parent can take to strengthen their case. Here are some things that may position them well for having their long-term care claim granted:

  • Seek coverage early so that the insurance company can’t claim that the condition was pre-existing.
  • Understand the limits of the policy so that your parent can act accordingly to ensure that they have the full coverage needed.
  • Seek medical treatment frequently and in accordance with the doctor’s recommendations so that the full extent of the condition is more easily seen.
  • Keep a journal of how Alzheimer’s has affected the ability to function appropriately from a physical and cognitive perspective.
  • Have a plan of care created if the policy in question requires one, ensuring that it is as detailed as needed.

Does your parent need help addressing their denied long-term care claim?

Alzheimer’s treatment can be enormously expensive, and Medicaid won’t cover the care that’s needed. Yet, your parent probably needs extensive care and supervision that you can’t personally provide, which is why insurance coverage is so important.

We know that a denied claim can be depressing and frustrating, but that’s not the end of the road. Your parent might be able to successfully appeal the claim denial, which will better ensure that they’re able to receive the care that they need. It’s not an easy process, though, which is why your parent might benefit from having a legal ally on their side as they fight for the outcome that is best for them.