The caregiver’s invoice arrives, but the insurance payment does not. After years of paying premiums, a denial can leave you questioning how to pay for assistance that has already become part of daily life. Long-term care insurance pays benefits for covered care when policy requirements are met, often involving physical limitations or cognitive impairment. An appeal asks the insurer to reconsider its decision using the policy language and supporting evidence.
A denial does not necessarily end your claim. Start by identifying the reason, checking deadlines, and gathering records that address the insurer’s objections. At The Law Office of Kevin M. Zietz, we represent policyholders facing disputed insurance benefits. Schedule a consultation with us promptly so we can review your denial and determine what your appeal needs before the filing deadline.
Identify Exactly What the Insurer Disputed
Read the denial alongside your complete policy, including endorsements and amendments. The insurer may dispute whether you meet a benefit trigger, whether your caregiver qualifies, whether the waiting period has ended, or whether required documentation was submitted. These issues call for different responses; simply repeating that care is necessary may leave the stated objection unanswered.
Our long term care insurance attorney can compare the insurer’s explanation with the actual contract requirements. Request the specific provisions relied upon and copies of assessments or other materials supporting the decision. Keep the denial letter, its envelope, and any electronic delivery notice to document when you received it.
Also distinguish a coverage denial from a request for missing information. If the insurer says records are incomplete, ask which documents are needed and whether the claim remains pending. Record every response rather than relying on an adjuster’s verbal assurance.
Confirm Deadlines Before Gathering More Records
There is no single appeal deadline that applies to every long-term care policy. Review the denial notice, policy procedures, and any applicable plan documents immediately. Calendar both the appeal deadline and potential lawsuit deadlines, which may differ.
Employer involvement can raise questions about the Employee Retirement Income Security Act, or ERISA. Its application depends on the arrangement, and long-term care coverage should not automatically be treated like disability income insurance. The U.S. Department of Labor’s claims guidance distinguishes benefit categories and procedural requirements. Our insurance denial attorney can determine which rules govern your claim and whether an administrative appeal is required before litigation.
Do not assume that requesting records or discussing the denial extends a deadline. Obtain written confirmation of any extension and legal advice about its effect. Waiting for a doctor’s report can otherwise consume time you need to submit a timely response.
Document the Assistance You Actually Need
A diagnosis alone may not establish eligibility. The evidence should explain what assistance or supervision is required, how often it is needed, and when those limitations began. Ask treating providers to connect their findings to the policy’s benefit criteria.
The California Department of Insurance’s long-term care guide explains that tax-qualified policies use benefit triggers involving substantial assistance with at least two specified daily activities or substantial supervision because of severe cognitive impairment. Other conditions, including certification and a care plan, may apply. Our long term care insurance lawyer can identify the evidence needed under your particular policy.
Useful supporting materials may include:
- Medical records and assessments describing functional limitations or cognitive impairment.
- Caregiver logs showing specific assistance, frequency, and safety concerns.
- A current care plan, provider information, invoices, and proof of payment.
Describe ordinary days accurately. If someone can dress independently only occasionally, explain that variation rather than presenting an isolated successful attempt as the usual level of functioning. For cognitive impairment, document the supervision needed even when physical abilities remain intact.
Check Waiting Periods and Provider Requirements
An elimination period is the waiting period before covered benefits become payable. Policies may count calendar days or qualifying service days differently. Compare the insurer’s calculation with care dates and the contract’s counting method.
Our insurance claim attorney can review whether the dispute concerns eligibility, timing, or reimbursement. A qualifying medical condition does not automatically make every expense payable; provider requirements, covered settings, benefit limits, and exclusions also matter. Our practice areas include representation involving insurance benefit disputes.
Continue keeping invoices while the appeal is pending. If a relative submits documents for the policyholder, confirm that the insurer has any necessary authorization. Missing signatures or unclear authority can create avoidable processing problems.
Keep premium payments current unless a valid waiver applies. A pending appeal does not itself eliminate premium obligations. If the insurer disputes a waiver, review that issue separately so a benefits disagreement does not also become a lapse dispute.
Submit an Appeal That Answers Each Objection
Organize the appeal around the reasons given in the denial. Identify the claim number, disputed decision, requested benefits, relevant provisions, and supporting documents. Explain how each record addresses a particular objection instead of sending an unexplained stack of medical files.
Our denied insurance claim lawyer can help present that connection clearly and identify gaps before submission. Kevin M. Zietz’s attorney profile provides background on his insurance litigation practice. Follow the required submission method, retain the complete appeal package, and obtain delivery confirmation.
Assess Your Options if the Denial Continues
A second denial warrants review of the insurer’s reasoning and available remedies. Depending on the governing law and facts, further action may involve additional review, a regulatory complaint, or litigation. An incorrect denial does not automatically establish insurance bad faith.
Our insurance dispute attorney can evaluate the claim handling, remaining deadlines, and possible next steps. A complaint should not be treated as a substitute for a required appeal or assumed to pause litigation deadlines.
Put Your Claim in a Position for Meaningful Review
Care expenses continue while coverage remains disputed, making a focused legal review valuable before another deadline passes. The Law Office of Kevin M. Zietz can assess your policy, identify weaknesses in the denial, and advise you on pursuing available benefits. Bring your denial letter and policy, and contact us today to discuss your next step.
When people invest in long-term care (LTC) insurance, they expect it to provide financial relief during some of life’s most challenging moments – when aging, illness, or disability make everyday living difficult. But many are shocked to discover their long-term care claims are denied.
If you’ve experienced denied long-term care insurance claims, it’s essential to understand the common reasons behind denials, what rights policyholders have, and how the appeals process works.
Statistics of Denied Long-Term Care Insurance Claims
Data from the 2022 Milliman Long-Term Care Insurance Survey reveals a stark reality: many long-term care insurance applications are denied from the outset.
- Ages 40–49: 12.4% claims are denied
- Ages 50–59: 20.4% claims are denied
- Ages 60–64: 30.4% claims are denied
- Ages 65–69: 38.2% claims are denied
- Ages 70-74: 47.2% claims are denied
These figures demonstrate how age can significantly impact approval rates, often due to underlying health conditions or risk factors flagged during underwriting. But even after a long-term care insurance policy is issued, claims may still be denied later, long after premiums have been paid.
Why Long-Term Care Insurance Claims Get Denied
Long-term care can be expensive, yet related costs continue to rise in the United States – alongside the never-ending denial of some (if not most) long-term insurance claims.
Here are some of the reasons why long-term care insurance claims are denied:
Insufficient Documentation
Many denials stem from incomplete, inconsistent, or unclear medical records. For instance, daily caregiver notes, treatment records, or care plans may be missing or fail to match the insurer’s criteria. Insurance companies may claim they never received the required forms or dispute the care provider’s qualifications.
Disputes Over Medical Necessity/Functional Impairment
Long-term care policies typically require the insured to be unable to perform at least two Activities of Daily Living (ADLs), such as bathing, dressing, or toileting, or to suffer from cognitive impairment. If the insurance company disagrees with the doctor’s certification or claims there is insufficient evidence of impairment, they may deny the claim.
Some insurers require documentation from specific healthcare providers or certified assessors. If the policyholder submits evaluations that don’t meet the insurance company’s strict standards, the claim may be rejected.
Failure to Meet “Benefit Triggers.”
To qualify for benefits, policyholders must meet the policy’s “benefit trigger” – a medical condition or functional limitation that initiates eligibility. These triggers are often tied to ADLs or cognitive decline. However, insurers may argue that the condition does not yet meet the threshold for coverage, especially if the need for assistance is occasional or intermittent.
Waiting Period Not Met
Most long-term care policies have a waiting period, also known as an elimination period, ranging from 30 to 90 days. Some policies only count the days on which paid care is received (service days), rather than calendar days. If the policyholder has unpaid caregivers or intermittent care, the waiting period may be extended, delaying benefits or leading to outright denial.
Pre-Existing Conditions
Insurers can deny claims by arguing that the condition requiring care was pre-existing and thus excluded. While California policies must clearly disclose exclusionary periods, these clauses are still used to contest benefits, especially for degenerative conditions that may have been undiagnosed at the time of application.
Lack of Coverage at Time of Claim
Coverage lapses due to missed payments or misunderstood policy expiration terms can also result in a denied long-term care insurance claim. Some insurers send minimal notice before terminating a policy, especially for elderly policyholders with memory issues.
Non-Covered Services or Settings
Some policies cover only institutional care (such as skilled nursing facilities), while others are limited to home-based services. A denial may occur if the care was received in an unlicensed facility or from an unapproved provider, even if the policyholder was otherwise eligible. Some long-term care policies may also impose outdated benefit limits, such as lower caps for assisted living or the exclusion of adult day care programs altogether.
How to Appeal After a Long-Term Care Insurance Denial
If your long-term insurance claim was denied, you are not without options. California law offers policyholders a pathway to appeal and contest a denial.
Request a Written Explanation
Under the California Insurance Code, insurers must provide a written explanation for any denial. This includes the specific reasons for the refusal and any policy language supporting it. Review this carefully to understand the basis of the dispute.
Review the Policy in Detail
Examine your policy for key provisions, including:
- Definitions of disability and benefit triggers
- Covered services and providers
- Elimination period and benefit caps
- Requirements for medical certifications
Gather Comprehensive Documentation
To counter the denial, collect:
- Updated medical records and physician statements
- Functional assessments that show ADL limitations
- Caregiver logs or notes
- Provider licenses and invoices
- Evidence of timely premium payments
Submit a Formal Appeal
Most insurers allow internal appeals. This usually involves submitting a written appeal with supporting documentation by a specific deadline. If the appeal is denied again, you may file a complaint or pursue legal action.
Consistency and specificity are crucial when appealing a denied insurance claim. A long-term care insurance lawyer can help ensure your appeal meets the insurer’s evidence standards.
Entrust a Denied Long-Term Care Insurance Claim to a Lawyer
Appealing an LTC insurance denial is time-sensitive and can be legally technical. Insurers may rely on internal guidelines, contracted third-party reviewers, and complex policy language to maintain their position.
Many claimants give up after a single denial, but the reality is that many appeals succeed with proper legal guidance.
A long-term care insurance claim lawyer can:
- Analyze the policy’s legal terms
- Challenge improper interpretations or bad-faith conduct
- Coordinate with physicians and care providers to develop stronger records
- Represent you in appeals, negotiations, or litigation
At The Law Offices of Kevin M. Zietz, we have proven experience in helping our clients with long-term care and disability insurance disputes in California. Call us today to schedule a free consultation and get started on your appeal.
Long-term care (LTC) insurance covers the costs of nursing home and/or assisted living services. Under most long-term care policies, a person is eligible for benefits when they are not able to do at least two out of six “activities of daily living” without the assistance of a home health professional, or they suffer from dementia or other cognitive impairment. The activities of daily living are:
- Bathing.
- Caring for incontinence.
- Dressing.
- Eating.
- Toileting (getting on or off the toilet).
- Transferring (getting in or out of a bed or a chair).
LTC insurance is expensive. According to the Alzheimer’s Association, the estimated cost for end-of-life care in 2019 ranged between $233,000 and $367,000. Most health and disability insurance will not cover long-term care, but long-term care insurance will.
Long-term care insurance policies may have limits on how long or how much they will pay. Some policies will pay the costs of long-term care services for two to five years, while other insurance companies offer policies that will pay for a person’s long-term care costs for as long as they live, regardless of cost.
Unfortunately, in the ongoing effort to cut their costs, insurance companies routinely deny valid LTC insurance claims based on technical requirements in the policies. Insurance companies also deny LTC claims by disputing that a person’s medical condition requires the level of care covered by the LTC policy, or by suggesting that those seeking benefits are receiving more care than is necessary or have been placed in the wrong type of facility.
If you have questions about what your options are after an insurance company has denied a claim for LTC benefits, call attorney Kevin M. Zietz for a free consultation.
