Long-term care claims and why they get denied

Long-term care claims have a distinctive difficulty: they arise long after purchase, often when the policyholder has cognitive impairment, and are frequently handled by family members who have never seen the policy.

The benefit triggers

Most policies pay when the insured either cannot perform a specified number of activities of daily living — usually two of six — or has a severe cognitive impairment requiring substantial supervision.

The six activities are typically bathing, dressing, toileting, transferring, continence and eating.

The definitions matter. "Cannot perform without substantial assistance" is assessed differently by different insurers, and standby assistance versus hands-on assistance is a distinction some policies draw.

Bathing is generally the first activity people lose, which is why it appears in most claims.

Why claims are denied

Trigger not met. The assessment concludes the insured can perform enough activities independently.

This is the most common reason and frequently turns on documentation rather than on the underlying reality.

Care setting not covered. Older policies frequently covered nursing home care only, or covered home care narrowly, or required a prior hospital or nursing home stay before home care benefits began.

Policies written decades ago may not contemplate assisted living facilities at all.

Provider not qualified. Many policies require care from licensed providers or licensed facilities.

Care provided by a family member, or by an informal helper, is frequently not covered — which surprises families who arranged the most practical care rather than the one the policy contemplated.

Some newer policies do allow family caregiver compensation with conditions.

Elimination period not satisfied. The waiting period may be measured in days of service received rather than calendar days, so someone receiving care three days a week takes far longer to satisfy a ninety-day period than expected.

Some policies require the elimination period to be satisfied only once per lifetime; others per claim.

Documentation insufficient. Care logs, physician certification and assessments not provided in the required form.

Policy lapsed. A serious issue, discussed below.

The lapse problem

Particularly cruel in this context.

Someone developing cognitive impairment may stop paying premiums — not from choice but because they no longer manage their affairs.

The policy lapses precisely when it is about to be needed.

Most states now require insurers to offer a third-party notice designation, allowing a family member to be notified before lapse, and to provide a reinstatement right where lapse resulted from cognitive impairment.

Designate a third party for lapse notices on every long-term care policy. This is free and it prevents the worst outcome.

Where a policy has lapsed and cognitive impairment was the cause, request reinstatement, citing the applicable state provision. These requests frequently succeed.

Filing the claim properly

Find the policy and read it in full, including the benefit triggers, covered settings, provider requirements and elimination period.

Get a physician certification documenting the specific activities of daily living the insured cannot perform without substantial assistance, or the cognitive impairment.

Generic statements do not work. The certification must address the policy's specific triggers.

Keep a care log from the beginning: dates, times, who provided care, what assistance was given with which activities.

This is the evidence base and it cannot be reconstructed.

Verify the provider qualifies before engaging them, in writing from the insurer.

Arranging care from a provider who does not meet the policy definition, and discovering it after months of payments, is a common and expensive error.

Expect an assessment. The insurer will typically arrange an in-person or telephone assessment.

Prepare for it as you would any benefit examination — accurately, without exaggeration, and with the family caregiver present to describe what assistance is actually required.

People with cognitive impairment frequently present better in a short interview than they function day to day. The caregiver's account matters.

Appealing a denial

Request the specific reason and the criteria applied.

Obtain a detailed physician letter addressing each trigger.

Submit the care log documenting the actual assistance provided.

Consider an independent geriatric assessment.

Escalate to the state insurance department, which handles these complaints and which has taken interest in long-term care claim practices.

And consider an elder law attorney, since these claims involve substantial sums over years.

What families should do in advance

Know whether a policy exists, where the documents are, and what it covers.

Designate a third party for lapse notices.

Ensure someone has legal authority to act — a durable power of attorney — before capacity is lost, because obtaining guardianship afterward is slow and expensive.

Read the policy before care is needed rather than during a crisis.

And keep paying the premium.

General information about insurance claims, not insurance, legal or medical advice. Policy terms, triggers and state protections vary. Consult the policy documents, a licensed advisor and an elder law attorney.