Can Your Long-Term Care Insurance Deny a Claim? What Happens if They Do?

You may not think much about your Long-Term Care Insurance policy until the day you or a loved one needs extended care. When that moment comes, you expect the policy you’ve paid into for years to do what it was designed to do: pay for high-quality support that protects your family and your savings.

Most of the time, that is precisely what happens. But not always. A small percentage of claims run into problems. Understanding why and knowing how to respond can make the difference between a smooth approval and a stressful delay.

Most Long-Term Care Claims Are Approved

Before diving into denials, you should know that the overwhelming majority of LTC Insurance claims are paid without controversy.

According to the 2025 AHIP State-to-State Long-Term Care Insurance Report, insurers paid $16.8 billion in benefits in 2024 alone, supporting quality care for policyholders nationwide. Since the inception of Long-Term Care Insurance, carriers have paid more than $193 billion in long-term care benefits.

Those payments cover:

• In-home care
• Assisted living
• Memory care
• Adult day services
• Nursing homes
• Hospice and end-of-life care

This data shows the real purpose of LTC Insurance: policies consistently pay claims on an enormous scale.

But when a denial does occur, it almost always falls into one of a few predictable categories.

When a Claim Can Be Denied

Even legitimate claims can be delayed or denied if they don’t meet policy requirements. The most common reasons include:

1. You Have Not Yet Met the “Benefit Trigger”

All tax-qualified LTC policies use the same federal standards. To qualify for benefits, a licensed health care provider must certify that you:

• Need help with two or more Activities of Daily Living (ADLs)—such as bathing, dressing, toileting, transferring, continence, or eating—for at least 90 days, or
• Have a severe cognitive impairment, such as Alzheimer’s or another dementia, requiring supervision for safety.

If documentation is incomplete or unclear, the insurer may pause or deny the claim until clarification is provided.

Sometimes, a policyholder or family member wants help, but does not need help. The help is either "hands-on" or "stand-by" assistance. The trigger for benefits is mandated under federal regulations for Long-Term Care Insurance.

2. The Care Provider Does Not Meet Policy Requirements

LTC policies typically require that caregivers or facilities be:

• State-licensed
• Operating legally
• Providing care consistent with the policy’s definitions

Informal caregivers who are not licensed, or facilities that do not meet state regulations, may not qualify—unless your policy includes a cash benefit that allows more flexibility.

3. The Plan of Care is Missing or Incomplete

Insurers require a written Plan of Care created by a physician, nurse practitioner, RN, or care coordinator. Missing documentation is one of the top reasons for delays. Many times, the doctor's office fails to send documentation promptly.

4. The Elimination Period Was Not Satisfied

All policies include a deductible measured in days, not dollars (often 30–90 days). If care was not received on enough days to satisfy the elimination period, benefits cannot begin. Any care services provided by health insurance or Medicare will often satisfy the elimination period.

5. Premiums Lapsed

Although very few LTC Insurance policies lapse, if a policy lapsed before the claim event, it may not be eligible, although reinstatement options sometimes exist when cognitive impairment contributed to non-payment.

6. The Claim Was Filed Incorrectly or Too Late

Incomplete forms, missing signatures, or failure to submit provider invoices can create unnecessary obstacles.

How the Claims Process Works

Knowing the process helps you avoid the red flags that lead to denials.

Step 1: Notify the Insurance Company

You or your representative contacts the insurer to open a claim. The insurer assigns a claims representative to guide you. If you have a Long-Term Care Insurance specialist, as opposed to a financial advisor or general insurance agent, they may help you with the process.

If you or a loved one needs help with an LTC Insurance claim, LTC News partners with Amada Senior Care to provide free claim support with no cost or obligation— File a Long-Term Care Insurance Claim.

Step 2: Provide Required Documentation

This usually includes:

• A physician’s statement
• Medical records
• A Plan of Care
• Proof of need for ADLs or cognitive supervision
• Facility or caregiver licensing documents

Step 3: Assessment by the Insurer

A nurse or care coordinator, sometimes in person, sometimes virtually, verifies the level of impairment and care needs.

Step 4: Elimination Period

Benefits begin after the policy’s elimination period is satisfied.

Step 5: Ongoing Benefit Payments

Once approved, insurers pay benefits monthly or reimburse eligible invoices, depending on policy type. The insurance company can either pay the provider directly upon receiving an invoice or reimburse the policyholder for services paid by them.

For families already under stress, a professional LTC claims advocate or care coordinator can be invaluable in managing paperwork and communication.

How to Appeal a Claim Denial

A denial does not mean the process is over. Under federal and state insurance law, you have the right to appeal.

Here’s how to strengthen your case:

1. Request the Denial Letter in Writing

The letter must state the specific reason for the denial and the evidence used.

2. Provide Updated Medical Documentation

Ask your doctor or neurologist to clearly document:

• ADL limitations
• Cognitive test results
• Safety risks
• Medication impacts
• Expected duration of impairment

The more concrete the evidence, the faster the reversal.

3. Obtain a New Plan of Care

A detailed Plan of Care that addresses the frequency, type, and duration of services often resolves insurer uncertainty.

4. Ensure the Care Provider Meets Licensing Requirements

If a caregiver or facility lacked state credentials, switching providers or adjusting billing can solve the issue.

5. Submit an Internal Appeal

Every insurer must offer at least one internal review, usually completed in 30–60 days.

6. Use an External, Independent Review

If the internal appeal fails, most states require insurers to allow an external review by an independent medical reviewer.

7. Seek Professional Help

Many families understandably start by asking, "Can insurance deny a claim?" and quickly discover that there are often patterns behind how and why insurers say no. This is where having an experienced advocate on your side becomes critical.

Elder law attorneys, LTC claims specialists, and state insurance departments can intervene when a consumer is being treated unfairly.

There are several law firms that specialize in this area, like Richardson Richardson Boudreaux in Oklahoma, which holds insurance companies accountable for unfair denials. 

Why Claim Problems are Usually Fixable

Experience shows that most denials stem from paperwork, not bad faith. Because the LTC Insurance industry pays billions yearly and has strong regulatory oversight, insurers have no incentive to deny legitimate claims.

Once medical evidence and care documentation are clarified, claims are routinely overturned on appeal.

Why This Matters for Your Retirement Plan

Long-term care is a financial and emotional risk no family can ignore. LTC Insurance is one of the most effective tools for:

• Protecting retirement savings
• Offering choice between home care, assisted living, and high-quality facilities
• Reducing the emotional burden on spouses and adult children
• Ensuring dignity and independence during vulnerable years

When a claim is denied, it is often not the end of the road. It is usually a signal that one more step is needed.

Final Thought: Don’t Go Through the Claims Process Alone 

If you or a loved one is preparing to file a Long-Term Care Insurance claim, or if a claim has been denied, guidance is available. Understanding what insurers need—and how to present it—can help you secure the benefits you paid for and protect the dignity and security of the person needing care.

Seek legal help if you are getting nowhere with the insurance company. While this doesn't happen often, it happens. Don't accept an insurance company's "no" as final.

And if you’re not yet at the claims stage, now is the time to review your policy, update your contact information, and ensure your family understands the claims process.

If you have not purchased an LTC policy yet, be sure to seek professional help. A qualified Long-Term Care Insurance specialist who represents the top name in the industry has likely experienced many claims and can help you get the best coverage at the lowest cost.