Long-term care daily allowance insurance – if the long-term care insurance does not pay out
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If the daily care allowance is refused
For many policyholders, daily care allowance insurance is an important component of their private long-term care insurance. It is designed to provide financial security in the event of needing care and to pay out a contractually agreed daily rate, regardless of the actual care required.
However, if it comes to Rejection Those affected often face considerable pressure when their benefits are denied, they are reclassified into a lower care level, or their policy is even terminated by the insurer. Especially in cases of long-term care needs, the refusal of payment can have existential consequences.
Rogert & Ulbrich, represented as lawyers in Insurance law We represent clients nationwide in disputes with their long-term care insurance providers. Our law firm reviews benefit denials, expert opinions, and contract clauses, and rigorously enforces legitimate claims.
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3When does the long-term care daily allowance insurance pay out?
A prerequisite for receiving benefits from long-term care daily allowance insurance is the existence of a need for care. A person is considered in need of care if, due to health impairments, their independence or abilities are significantly restricted and they are expected to require assistance for at least six months.
The determination is usually made through a care assessment. For those with statutory health insurance, the assessment is regularly carried out by the Medical Service, while for those with private insurance, the private health or long-term care insurance company often commissions its own assessors.
The decisive factor is the assigned care level. The amount of the daily care allowance depends on the contractually agreed daily rate and the respective care level. The benefit is paid regardless of the actual care costs incurred.
If a dispute arises regarding the classification or recognition of the need for care, a legal review by a lawyer specializing in insurance law is advisable.
We will take care of your case – quickly & with commitment.
Binding adherence to the care assessment and dispute over the care level
Many contracts stipulate that the long-term care daily allowance insurance is tied to the outcome of the care assessment. Nevertheless, disputes repeatedly arise regarding the evaluation of individual modules or the weighting of the points.
If a care level is determined to be too low, this has a direct impact on the amount of benefits. In such cases, legal action can be taken against the long-term care insurance fund under social law, as well as against the private insurer under insurance law.
A coordinated legal strategy is essential, particularly at the intersection of social security law and insurance law. Our firm will assess which steps are appropriate in your specific case.
If your insurance company is causing problems – talk to lawyer Dario Kovac
Is your insurance company refusing to pay or delaying the settlement? Lawyer Dario Kovac He has been assisting clients with disputes with insurance companies, particularly legal expenses insurers, since 2019. His previous work at ARAG He is familiar with typical rejection strategies from practice.
- Review of your benefit claim
- Consistent enforcement
- No communication with the insurance company
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Special considerations for children requiring care
Children are subject to special standards. Their care level is not considered in isolation, but rather determined in comparison to a healthy child of the same age and development. This results in different assessment criteria.
If the application is rejected or the assessment is deemed inaccurate from the parents' perspective, the report should be carefully reviewed. Particularly in cases of developmental delays or cognitive impairments, a nuanced description of the actual support needs is often crucial.
A lawyer specializing in insurance law can provide support and consistently represent the family's interests.
Pre-contractual disclosure obligation and termination by the insurer
It is not uncommon for insurers to allege a breach of pre-contractual disclosure obligations when a claim is made. This stems from health-related questions that had to be answered during the application process.
If the insurer relies on incomplete or incorrect information, it can, under certain conditions, contest or withdraw from the contract. For the affected policyholders, this could mean, in the worst case, the loss of insurance coverage.
Whether a breach of the duty to disclose information has actually occurred depends on both objective circumstances and the policyholder's subjective knowledge. Not every inaccurate statement automatically entitles the insurer to terminate the policy.
An experienced lawyer specializing in insurance law checks whether the conditions for withdrawal or contestation are actually met.
Spontaneous reporting obligation and allegations of fraudulent intent
Insurers sometimes argue that certain illnesses or developmental abnormalities should have been disclosed even without being explicitly asked. However, such a so-called spontaneous duty to disclose exists only in very limited exceptional cases.
Furthermore, in the event of a claim based on fraudulent misrepresentation, the insurer must prove that the policyholder knowingly and intentionally provided false information. The burden of proof lies with the insurer.
Here too, a thorough legal review by a specialized lawyer is advisable.
Practical examples from long-term care daily allowance insurance
In one case, the long-term care insurance company refused benefits, arguing that the assessed care level was insufficient for the contractually agreed benefit level. Following a reassessment and legal arguments, a higher classification was obtained, which also increased the daily care allowance.
In another case, the insurer declared its withdrawal from the contract due to allegedly undisclosed pre-existing conditions. After legal review, it turned out that the health-related questions were worded ambiguously and that there had been no intentional misrepresentation. The insurance coverage remained in effect.
These cases show that involving a lawyer in insurance law can be crucial.
10 Questions & Answers about Long-Term Care Insurance
Have your benefit denial legally reviewed now.
If your long-term care insurance refuses benefits, does not recognize the level of care required, or wants to terminate the contract, you should not accept the decision without having it reviewed.
Have your case reviewed by an insurance law attorney to clarify what claims you are entitled to under your long-term care insurance policy. Schedule an initial consultation with our law firm.
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