Long-Term Care Insurance Denied: How to Appeal and Get Coverage

Long-Term Care Insurance Denied: Understanding Your Rights and How to Fight Back

Long-term care (LTC) insurance is designed for one of the most vulnerable moments of a person's life — when they can no longer care for themselves and need assistance with daily activities. Having a claim denied at that moment is devastating. These denials are also, very frequently, wrong.

LTC insurance denials often hinge on technical assessments of functional ability and cognitive capacity. Understanding how these assessments work, where they go wrong, and how to challenge them is the foundation of a successful appeal.

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How Long-Term Care Insurance Works: The Benefit Triggers

LTC policies pay out when the insured meets a defined threshold of need, typically described in terms of "benefit triggers." There are two main categories:

Activities of Daily Living (ADLs)

Most LTC policies require that the insured be unable to perform a certain number of the following six standard Activities of Daily Living without substantial assistance:

1. Bathing — washing oneself
2. Continence — managing bladder and bowel function
3. Dressing — putting on and removing clothing
4. Eating — feeding oneself
5. Toileting — getting to and from the toilet
6. Transferring — getting in and out of bed or a chair

Most policies trigger benefits when the insured cannot perform 2 or more ADLs without substantial assistance. Some policies require inability with 3 or more.

Cognitive Impairment

The second major trigger is severe cognitive impairment — defined in most policies as a deterioration or loss of intellectual capacity that requires substantial supervision to protect the insured from threats to their health or safety. This covers conditions like Alzheimer's disease and other forms of dementia.

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Why Long-Term Care Claims Are Denied

ADL Assessment Disputes

The most common denial basis is an insurer-commissioned assessment that finds the claimant "independent" or "minimally dependent" in ADLs — contradicting what family members and the treating physician observe daily.

These assessments are often conducted by nurses or occupational therapists hired by the insurer and conducted in a single visit. Problems include:

• The assessment occurs on a "good day"
• The assessor uses a more lenient definition of "independent" than the policy requires
• The assessment doesn't account for safety risks involved in the ADL performance
• The assessment ignores the time required to complete ADLs (performing an ADL in 20 minutes when it used to take 5 minutes may still constitute need for assistance)

Cognitive Impairment Underestimation

Cognitive assessments using tools like the Mini-Mental State Examination (MMSE) or the Montreal Cognitive Assessment (MoCA) measure test performance in a structured, brief clinical encounter. They may understate real-world functional deficits that manifest in familiar home settings over a full day.

Policy Exclusions

• Pre-existing conditions (if the condition manifested before the policy was issued or during the exclusion period)
• Conditions excluded by name in the policy schedule
• Care provided by family members in some policies

Administrative Grounds

• Claiming during the elimination period (the waiting period before benefits begin — commonly 30, 60, or 90 days)
• Failure to use a licensed care provider
• Care not qualifying as "skilled" or "custodial" care as defined in the policy

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Step 1: Request the Full Assessment Report

Immediately after a denial, request:

• The full written report from the insurer's assessor, including their credentials and methodology
• The specific policy provisions the insurer says the claimant does not meet
• All documentation relied upon in making the denial decision

Read the assessment report carefully. Common errors include:

• Observations that contradict what the claimant's family and physician report
• ADL assessments conducted without asking about safety risks
• Failure to assess all six ADLs

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Step 2: Get Your Physician and Care Team Involved

Your appeal should include a comprehensive physician's report that:

• Provides the formal diagnosis and a clinical description of how it affects daily functioning
• Specifically addresses each ADL the insurer found the claimant to be independent in, explaining why the clinical picture supports a finding of dependence
• For cognitive impairment cases: provides a detailed neuropsychological assessment (if not already done) from a neuropsychologist or geriatric psychiatrist

The insurer's single-visit assessment carries much less weight than a longitudinal clinical picture provided by a treating specialist who sees the patient regularly.

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Step 3: Commission an Independent Functional Assessment

Hire an independent occupational therapist (OT) to conduct a comprehensive ADL assessment in the home environment. This is critical because:

• Home-based assessments capture actual performance in the real environment, not a clinic
• OTs can assess how long ADLs take, how safely they're performed, and what supervision is required
• Independent OTs have no financial incentive to find the claimant more capable than they are

The independent OT's report directly counters the insurer's assessment and gives the appeals team (and any subsequent ombudsman or court) competing expert evidence to weigh.

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Step 4: Document the Daily Reality

Care journals and caregiver logs are powerful appeal evidence. Have family members or professional caregivers keep a detailed daily log for 2–4 weeks documenting:

• What assistance is provided with each ADL and why
• Any safety incidents or near-incidents
• Times and duration of assistance
• The claimant's behavior, confusion, or resistance

This real-world record is impossible for the insurer to dismiss with a single assessment visit.

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Step 5: File a Formal Written Appeal

Your formal appeal should include:

• A point-by-point rebuttal of the insurer's assessment findings
• Your physician's clinical report addressing each denied benefit trigger
• The independent OT assessment
• Caregiver/family daily logs
• Any additional diagnostic reports (neuropsychological evaluation, imaging, specialist notes)
• A specific legal argument if the policy language is ambiguous

Under US state insurance law and similar regulations internationally, LTC insurers must handle appeals fairly and within defined timeframes. Most state insurance departments require a decision on LTC appeals within 30–45 days.

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Regulatory Options by Country

United States

• Internal appeal to the insurer (required before external options)
• External review through your State Department of Insurance
• Some states have specific LTC insurance oversight units with enhanced consumer protections
• The National Association of Insurance Commissioners (NAIC) Long-Term Care Insurance Model Act sets minimum standards
• Legal action for bad faith claims handling in states with strong bad faith statutes

Contact your State Department of Insurance — most have dedicated LTC insurance specialists.

United Kingdom

Long-term care products in the UK are regulated by the FCA. Disputes go to the Financial Ombudsman Service (FOS) within 6 months of the insurer's final response.

Australia

LTC and disability insurance claims go to AFCA. TPD (Total Permanent Disability) and income protection claims frequently involve similar functional capacity assessment disputes.

Canada

Contact your provincial insurance regulator or the General Insurance OmbudService (GIO).

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Common Mistakes in LTC Insurance Appeals

1. Not having an independent functional assessment done. This is the single biggest mistake. A single insurer assessment against which you only argue in words will not be effective.

2. Not keeping caregiver logs. Without a documented record of actual daily assistance, the insurer's assessment stands unchallenged by real-world evidence.

3. Missing the elimination period mechanics. If the insurer denied because benefits were claimed during the elimination period, ensure you understand exactly when that period ended and document qualifying care received during the period (even if not reimbursable, it may count toward the period's completion).

4. Accepting "doesn't meet ADL criteria" without checking the policy's ADL definitions. Some policies define "substantial assistance" or "independence" differently from clinical norms. Read the definitions section carefully.

5. Not involving a physician who specializes in the relevant condition. A geriatrician or neurologist carries significantly more authority in a cognitive impairment case than a GP's note.

6. Not appealing cognitive impairment denials that relied solely on MMSE scores. MMSE and similar screening tools miss many forms of cognitive impairment, particularly early or atypical dementia. A full neuropsychological evaluation frequently reveals deficits these tools don't capture.

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The Financial Stakes: Why It's Worth Fighting

LTC insurance benefits typically pay between $3,000 and $15,000 per month and can continue for years or even the rest of the insured's life. For policies with lifetime benefit periods, the total benefit value can easily exceed $1 million. Given these stakes, engaging an attorney who specializes in LTC insurance disputes is often justified for high-value cases.

Many LTC insurance attorneys work on a contingency basis for bad-faith claims — meaning you pay nothing unless they win.

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Writing Your LTC Appeal Letter

The appeal letter for an LTC denial must be detailed, clinical, and policy-specific. It needs to systematically address each ADL or cognitive function the insurer found unaffected and present the clinical and observational evidence that contradicts their assessment. ClaimBack can help you structure a formal LTC insurance appeal letter that addresses each denial ground with the appropriate evidence framework. Visit claimback.app to get started.

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Summary: LTC Insurance Appeal The Full Fight

1. Request the full assessment report and policy provisions the insurer relied on
2. Commission an independent OT assessment in the home environment
3. Get a comprehensive specialist physician's report that addresses each benefit trigger
4. Document daily reality with caregiver logs for 2–4 weeks
5. File a formal written appeal within the required deadline with all supporting evidence
6. Escalate to your State Department of Insurance or ombudsman if the internal appeal fails
7. Consider legal counsel for high-value claims or bad-faith conduct