Why Long-Term Care Insurance Claims Get Denied

Long-term care insurance can help pay for care when someone needs help with daily activities. Unfortunately, claims are sometimes denied. Understanding why can help prevent delays and unexpected expenses.

Common Reasons Claims Are Denied

Lack of Medical Documentation

• Insufficient records showing the policy’s benefit trigger is met

• Most policies require proof of:

  • Help with at least two activities of daily living (ADLs) (such as eating, bathing, or dressing), or

  • A severe cognitive impairment

• Claims may be denied if records do not clearly document these needs

Preexisting Condition Exclusions

• Some older policies exclude coverage for preexisting conditions

• Claims may be denied if:

  • Care is needed during the exclusion period, or

  • The insurer believes the condition existed before coverage began

Not Understanding What’s Covered

• Not all care or facilities are covered

• Some policies:

  • Cover only licensed providers

  • Do not cover independent caregivers or family members

  • Require assisted living facilities to meet specific standards

Elimination Period Issues

• The elimination period is the number of days care must be paid for before benefits start

• Claims may be delayed or denied if:

  • Care is not continuous, or

  • Documentation is incomplete during this period

Administrative or Technical Errors

• Incomplete forms

• Missing signatures

• Paperwork mistakes

How to Help Prevent Claim Denials

• Review your policy before care is needed

• Understand benefit triggers, covered services, and exclusions

• Confirm care providers meet policy requirements

• Keep detailed medical records and care documentation

• Track care and expenses during the elimination period

If Your Claim Is Denied

• Read the denial letter carefully

• File an appeal within required deadlines

• Include updated medical records and care documentation

• Seek help from your state’s Department of Insurance, consumer protection programs, certified long-term care insurance specialists, or an elder law attorney if needed

Bottom Line

Long-term care insurance claim denials can be frustrating, but many can be avoided or overturned. Understanding your policy, keeping thorough records, and knowing your appeal rights can improve your chances of receiving the benefits you planned for.

If you have questions about a long-term care insurance claim or need help understanding your options, McClelland Law Firm, P.A. can help guide you through the process.

📞 Contact McClelland Law Firm, P.A. today to schedule a consultation and get clarity and peace of mind.