Long-Term Care Insurance Denials: What to Do

Read the denial like a checklist

Do not start by writing a long letter about how sick the older adult is. First, find the sentence that says why the insurer did not approve payment. Long-term care claims often turn on contract details: whether the person met the benefit trigger, whether the waiting period was satisfied, whether the service was covered, and whether the provider fit the policy definition.

The federal Administration for Community Living explains that long-term care policies commonly use a benefit trigger and elimination period before benefits begin. Your own policy controls the actual claim, so read the schedule of benefits, riders, definitions, benefit-trigger section, elimination-period section, provider rules, and any waiver-of-premium language.

Ask the insurer to identify the exact policy page or provision used for the denial. Also ask whether the claim can be reconsidered with added records or whether you must use a formal appeal process. Keep the denial letter, envelope, portal message, and any appeal instructions together.

If the long-term care benefit is a rider on a life insurance or annuity contract, pull the rider pages too. The NAIC consumer overview notes that these combination products exist. The rider can contain its own benefit definitions, limits, and claim requirements.

Do not confuse an appeal with a complaint

An insurer appeal asks the company to change its benefit decision. A state insurance complaint asks the regulator to review how the insurer handled the matter. The National Association of Insurance Commissioners (NAIC) says state departments of insurance can review complaints about claim delays, denials, policy problems, and communication. Its NAIC complaint guide explains the general complaint process.

Unless the insurer or regulator confirms otherwise, treat the appeal deadline and a state complaint as separate tasks. Do not let one process cause you to miss the other.

When the benefit trigger is disputed

A diagnosis can explain why care is needed, but it may not by itself satisfy the policy. The strongest records show what the person cannot safely do and what help another person must provide.

For federally tax-qualified long-term care insurance, current IRS Form 8853 instructions define a chronically ill person as someone certified by a licensed health care practitioner as unable to perform at least two activities of daily living without substantial assistance for at least 90 days because of loss of functional capacity, or as someone who needs substantial supervision because of severe cognitive impairment. The six activities are eating, toileting, transferring, bathing, dressing, and continence.

That federal tax definition is important, but it does not replace the contract. Older or non-tax-qualified policies may use different wording. Ask the insurer which trigger applies to this specific policy.

Make records describe function

Useful notes are concrete: “needs one-person help to transfer from bed to chair,” “cannot bathe without hands-on help,” or “wanders at night and cannot be left alone safely.” A note that only says “dementia,” “arthritis,” “stroke,” or “needs assistance” may leave the insurer without enough detail.

For home care, compare the policy’s provider rules before hiring someone. The GFS guide to home care agencies explains practical differences between agencies and independent caregivers, but the policy decides which type of care can be reimbursed.

When the waiting period is disputed

The elimination period is the time that must pass after the benefit trigger is met before the insurer begins paying under the policy. The ACL elimination-period glossary distinguishes service-day periods from calendar-day or disability-day periods. Some policies require covered services on a day before that day counts; others use a different counting method.

Do not assume that “90 days” means 90 calendar days. Ask for a written ledger showing the insurer’s start date, every day it counted, every day it did not count, and the policy language behind that calculation. If paid care is required, unpaid family care may not satisfy the waiting period even though it is essential to the older adult.

If the dispute involves home services, keep daily logs showing the date, hours, caregiver, tasks, and amount paid. The GFS home care guide can help families compare common forms of home support before changing the care arrangement.

Build an appeal that answers the denial

A focused packet is usually easier to review than a large unsorted stack. Use the insurer’s instructions and keep proof of delivery.

1. Write a short cover letter. Include the insured person’s name, policy number, claim number, denial date, the exact decision being challenged, and the result you are asking for.
2. Attach the denial. Mark the stated reason without changing the original document.
3. Attach the controlling policy pages. Include only the sections that explain the trigger, waiting period, covered service, provider, facility, or premium issue.
4. Add stronger evidence. Use updated functional records, a current plan of care, care logs, itemized bills, licenses, and payment records that answer the insurer’s reason.
5. Confirm authority. If an adult child or caregiver is handling the claim, ask what insurer authorization, health-care proxy, or power-of-attorney document is needed. The GFS estate planning checklist explains common planning documents, but the insurer decides what it accepts for claim communications.
6. Prove delivery. Keep portal screenshots, fax confirmation, certified-mail records, or another trackable delivery record.
7. Follow up in writing. Ask whether the file is complete and when the insurer expects to issue its next decision.

Escalate the problem to the right place

If the insurer upholds the denial, keeps asking for the same material, gives conflicting explanations, or does not communicate clearly, find your state insurance department. Ask how your state handles long-term care insurance complaints and whether any separate review process applies.

If the dispute has become legally complex, especially around lapse, rescission, authorization, contract interpretation, or a large amount of unpaid care, low-income households can check the LSC legal aid finder. A lawyer can advise on state law and the specific policy; GFS cannot decide a legal claim.

The Eldercare Locator connects older adults and families to local aging services and can be reached at 1-800-677-1116. If a resident is in a facility, the ombudsman route is for resident-rights and facility issues, not for deciding whether the insurance company owes benefits.

Documents to gather before you call

• Denial letter and envelope or portal notice.
• Policy, schedule of benefits, riders, and outline of coverage.
• Claim number and insurer contact information.
• Doctor, nurse, therapy, cognitive, and facility assessments.
• Current plan of care.
• Daily care logs showing tasks, hours, and supervision.
• Itemized invoices and proof of payment.
• Agency or facility license information when provider qualification is disputed.
• Premium receipts and lapse notices when policy status is disputed.
• Authorization or power-of-attorney papers if someone else handles the claim.
• A call log with dates, names, titles, and promised next steps.

Keep copies. Do not mail original records unless the insurer specifically requires them and you have retained a copy.

Protect cash flow while the appeal is pending

Ask the facility or home care agency whether it can pause collection activity, set a payment plan, or give you time while the insurer reviews the appeal. Do not promise a payment date you cannot meet.

If the older adult may qualify financially and medically, Medicaid can be an important backup payer for long-term services and supports. Federal Medicaid information on Medicaid HCBS programs explains that states can provide services in homes and communities, but each state sets its own eligibility and program rules. The GFS Medicaid for seniors guide gives a plain-language starting point.

If assisted living is the care setting, the GFS guide to low-income assisted living explains other payment paths. If unpaid provider bills are being sent to collections and they are medical debts, review medical debt rights before agreeing that every charge is correct.

The National Institute on Aging also provides a long-term care payment guide. Local aging agencies may have respite, meals, transportation, or caregiver supports that do not replace insurance but can reduce pressure on the household budget.

If the family is deciding whether the older adult can remain at home or needs a residential setting, the GFS assisted living guide can help organize that decision separately from the insurance appeal.

Common mistakes to avoid

• Missing the appeal deadline while waiting for one more medical record.
• Sending a diagnosis without explaining daily function or safety needs.
• Assuming every day of care counts toward the elimination period.
• Hiring a provider before checking the policy’s provider definition.
• Sending hundreds of pages without a short cover letter that answers the denial reason.
• Stopping premiums before the insurer confirms a waiver or other policy provision applies.
• Assuming a regulator complaint automatically replaces the insurer’s appeal process.
• Letting a suspicious caregiver or provider control claim documents or benefit statements. If financial exploitation is a concern, see GFS guidance on elder financial abuse.

Phone scripts you can use