How Long-Term Care Insurance Works
Long-term care (LTC) insurance pays for assistance with activities of daily living (ADLs) when you can no longer independently perform a specified number of them—typically two or more of: bathing, dressing, toileting, transferring, continence, and eating. Coverage triggers also include cognitive impairment (Alzheimer's, dementia) that requires substantial supervision. Benefits cover nursing home care, assisted living, and in-home care, subject to daily or monthly benefit limits and an "elimination period" (deductible measured in days) before benefits begin.
Why LTC Claims Are Denied
Common LTC claim denial reasons include: the policyholder does not meet the functional assessment threshold (the insurer's assessor finds fewer ADL limitations than claimed); cognitive impairment doesn't meet the policy's "substantial supervision" standard; the care is not provided by a "licensed care provider" as defined in the policy; the claim was filed before the elimination period expired; or there are application misrepresentations. The assessment of functional limitations is highly subjective and insurer-hired assessors may evaluate differently than treating physicians.
Challenging a Functional Assessment
When an LTC claim is denied because the assessment found insufficient ADL impairment, the primary challenge is the independent medical opinion of the treating physician. Request the specific assessment report and criteria applied. Have the treating physician document specifically and comprehensively the policyholder's functional limitations in each ADL—level of independence, need for cueing, need for physical assistance, safety risk without assistance. Requesting an independent second assessment is often appropriate for borderline cases.
The Elimination Period and Proper Claim Initiation
Most LTC policies have an elimination period of 30–100 days—a period during which the insured must need and receive care before benefits begin. This functions like a deductible. Careful attention to when care began, documentation of care received during the elimination period, and notification to the insurer before or at the start of the benefit period are all procedurally critical. Retroactive claims filed long after care began are more likely to face documentation disputes.
Get your LTC insurance claim reviewed →
Discuss your case with Yates Anderson
Yates Anderson represents clients in Alabama, Florida, and beyond. Our attorneys handle complex disputes with the rigor of a national firm and the agility of a boutique. Request a case evaluation and an attorney will respond within one business day.
Frequently asked questions
My parent can't live independently but the insurance company says they don't qualify for benefits. What do we do?
Request the full assessment documentation and criteria from the insurer. Compare the assessor's findings specifically to your parent's actual daily functioning with the treating physician. File a formal written appeal with supporting physician documentation describing functional limitations in specific ADL terms the policy uses. If the internal appeal fails, consult a policyholder attorney specializing in LTC insurance—these claims have significant value and the investment in professional assistance is often justified.
Can a long-term care insurer raise premiums after I've been paying for years?
Yes, LTC insurers can request state regulatory approval to raise premiums, and many have. This was a significant industry problem in the 2010s and 2020s as claims experience proved worse than original pricing assumed. When premiums increase, policyholders typically have options: pay the increased premium; reduce benefits (daily benefit amount or benefit period) to maintain the original premium; or elect a paid-up policy status where you stop paying premiums and receive a reduced benefit.
Does LTC insurance cover memory care facilities for Alzheimer's?
Most LTC policies cover memory care facilities when the cognitive impairment triggers the policy's benefit criteria—typically requiring that the cognitive impairment results in a need for substantial supervision to protect the person's health or safety. Memory care facilities that are licensed as residential care facilities or assisted living with a memory care component typically qualify as covered facilities. Confirm that the specific facility is a "licensed care provider" as defined in your policy before admission.