What to Do If Your Long-Term Care Claim Is Denied

Receiving a denial letter after submitting a long-term care insurance claim is devastating — especially when a loved one is already in care and costs are mounting. But a denial is not a final answer. Most LTC claim denials can be appealed, and a significant number are overturned when handled correctly.

Here is what to do immediately after receiving a denial.

Step 1: Understand the Exact Reason for Denial

Your insurer is required to provide a written explanation of the denial. Read it carefully and identify the specific stated reason. Common denial reasons include:

• Failure to meet benefit trigger requirements
• Insufficient medical documentation
• Care provider not meeting policy standards
• Policy lapse due to missed premium payments
• Claim filed outside the notification window

The denial reason determines your appeal strategy.

Step 2: Request Your Complete Claim File

You have the right to request a full copy of your claim file from the insurer. This includes all documents submitted, all internal notes, and the assessor's report if an independent evaluation was conducted. Review everything for errors, omissions, or assessments that contradict your physician's findings.

Step 3: Gather Stronger Supporting Evidence

Address the denial reason directly with additional documentation:

• If benefit triggers were disputed — obtain a detailed functional assessment from your physician and, if possible, a second independent medical opinion
• If documentation was cited as insufficient — compile a more comprehensive package including specialist notes, hospital records, and a revised Plan of Care
• If the care provider was questioned — obtain documentation confirming their licensure and compliance with your policy's care standards

Step 4: Submit a Formal Written Appeal

Most policies provide for at least one internal appeal. Submit your appeal in writing, certified mail, within the deadline specified in your denial letter — typically 60 to 180 days. Your appeal should include a cover letter clearly stating the grounds for appeal, all supporting documentation, and a request for written acknowledgment.

Step 5: Escalate If Necessary

If your internal appeal is denied, you have further options:

• External review: Request an independent external review of the denial
• State insurance commissioner: File a complaint with your state's department of insurance — insurers take regulatory complaints seriously
• Legal counsel: For high-value claims, consult an attorney who specializes in insurance bad faith or elder law

Pro Tip

Document every interaction with your insurer — dates, names, and the content of every phone call and letter. If your claim eventually becomes a regulatory complaint or legal matter, this log is your strongest asset.

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