How Long-Term Care Insurance Claims Work: Triggers, Filing, and What to Expect

Not financial, legal, or tax advice. Policy terms vary — the claim rules in your specific contract govern. Read this as a framework, not as a substitute for your policy language.

Buying LTC insurance is the first decision. Knowing how to use it is the second — and most policyholders don't think about it until they're in the middle of a care crisis. This guide walks through how claims work for tax-qualified LTC policies: what triggers benefits, how to file, how the elimination period actually counts, and what happens when a claim is disputed.

The two benefit triggers

Tax-qualified LTC policies — the type almost everyone buys today — must meet IRS requirements under IRC §7702B. To receive benefits, a licensed health care practitioner must certify that you meet one of two triggers:¹

Trigger 1: Activities of Daily Living (ADLs)

You need substantial assistance with at least 2 of 6 Activities of Daily Living, expected to last at least 90 days. The six ADLs are:

• Bathing: Washing the body, including getting in and out of the tub or shower
• Dressing: Putting on and removing clothing, including fasteners and prosthetic devices
• Eating: Getting food from a plate or other container to the mouth
• Continence: Maintaining voluntary control over bowel and bladder functions, or performing associated hygiene
• Transferring: Moving in or out of a bed, chair, or wheelchair
• Toileting: Getting to the toilet and performing associated hygiene

"Substantial assistance" means either hands-on physical help or standby assistance (someone must be physically present to prevent injury). Verbal reminders alone typically don't qualify.

Trigger 2: Severe cognitive impairment

You have a severe cognitive impairment — such as Alzheimer's disease or other forms of dementia — that requires substantial supervision by another person to protect you from threats to your health or safety. This trigger does not require ADL failure. A person with early-to-moderate dementia who can still physically perform ADLs may qualify solely on cognitive grounds.

How to initiate a claim — step by step

Step 1: Notify the insurer

Call the claims department on your policy's declarations page. Most carriers require written notice of claim within a specific timeframe — often 30–60 days after care begins, though some policies allow longer. File sooner rather than later; late notice can delay benefits and, in rare cases, give the carrier grounds for denial.

Step 2: Complete the claim forms

The insurer sends a claims packet with three components:

• Claimant statement: Your (or your representative's) description of the need for care
• Physician statement: A licensed health care practitioner certifies the diagnosis, functional limitations, and expected duration of care need
• Facility or provider statement: If receiving care in a facility or from a home care agency, the provider certifies the level and type of services

The insurer may also require medical records — typically 2–3 years of history. Be prepared to authorize the release of records.

Step 3: The insurer's assessment

Most carriers send a registered nurse or case manager to conduct an independent assessment, typically in the policyholder's home or care setting. This is separate from your physician's certification and is the insurer's own evaluation of whether the benefit triggers are met. It is not adversarial by default — the case manager is gathering information — but how you present the actual care needs matters.

Document everything before the assessment: which ADLs require help and in what specific ways, how often, what happens when assistance isn't provided. Generalities ("sometimes needs help bathing") are harder to evaluate than specifics ("needs hands-on assistance getting in and out of the shower every day due to fall risk and balance deficit").

Step 4: Benefit approval and the care plan

If approved, the insurer typically establishes a care plan in coordination with a care coordinator (see below). Benefits become payable after the elimination period runs (see next section).

The elimination period in practice

The elimination period is the number of days you pay for care out-of-pocket before the policy starts paying. Standard is 90 days. Think of it as a deductible measured in time. A few mechanics to understand:

Calendar days vs. service days

Policies differ in how they count elimination period days:

• Calendar days: Every calendar day counts, whether or not you received care that day. A 90-day elimination period runs in roughly 3 months from first qualifying care. Most modern policies use this approach.
• Service days: Only days on which you actually receive covered services count. For intermittent home care (say, 3 days/week), it takes much longer to satisfy a 90-day elimination period — around 30 weeks at 3 days/week. Older policies sometimes used this method.

Check your policy's definition section for "elimination period" and how days are counted. This distinction can mean the difference between benefits starting in 3 months versus 7 months.

Once-in-a-lifetime elimination period

Many policies have a provision that once the elimination period is satisfied, it never has to be satisfied again — even for a subsequent care episode after a gap in benefits. If your policy has this feature, it applies only to claims filed while the policy is in force. Read your policy's "waiver of elimination period" or "once satisfied" language.

Benefit period start date

The benefit period (e.g., 3 years) begins after the elimination period is satisfied, not when care begins. A policy with a 3-year benefit period and a 90-day elimination period provides benefits for up to 3 years of care after day 90.

Reimbursement vs. indemnity (per diem) policies

How the policy pays benefits once you qualify matters as much as whether it pays:

Reimbursement policies are far more common. Indemnity policies are more valuable in practice (especially for informal care by family members or lower-cost home care) but are priced accordingly. If you bought a per-diem policy before the mid-2000s, it may be worth significantly more than you realize — carriers rarely sell them today.

Common claim denials — and how to appeal

Why claims are denied

The most common denial reasons:

• Benefit trigger not met: The insurer's assessment concludes fewer than 2 ADLs fail, or cognitive impairment isn't "severe" enough. This is the most contested denial type.
• Care not provided by a "qualified provider": Some policies require care from a licensed home health agency rather than an individual caregiver. Informal care by a family member may not qualify unless the policy has a cash benefit or informal care provision.
• Care setting doesn't qualify: Facilities must meet the policy's definition of covered care settings (skilled nursing facility, assisted living, memory care, adult day care, home health). Some older policies have narrow definitions that exclude certain assisted living arrangements.
• Pre-existing condition exclusion: If a condition existed before the policy's exclusion period (often 6 months), some policies won't cover LTC arising from it. Less common in modern policies but still appears.
• Lapse for non-payment: The policy was unknowingly lapsed. Check that automatic bank drafts are still active and that your insurer has your current address for premium notices.

The appeal process

Every denial must include a written explanation and the right to appeal. The standard process:

1. Internal appeal: File a written appeal with the insurer within the deadline stated in the denial letter (often 60–180 days). Include a letter from your physician addressing the specific denial reason, additional medical records, and a detailed description of care needs. Request a written decision on the appeal.
2. External review: If the internal appeal is denied, most states require insurers to offer independent external review by a licensed clinical reviewer. This is a meaningful consumer protection — external reviewers overturn insurer decisions in a significant percentage of cases.
3. State insurance department complaint: File a complaint with your state insurance commissioner. Regulators can compel the insurer to reconsider. Public complaint records also affect insurer licensing.
4. Legal remedies: In egregious cases, an elder law attorney can pursue breach of contract or bad faith claims. Keep every document: denial letters, appeal submissions, insurer responses, and all correspondence.

Care coordinator services

Most LTC policies include free care coordinator services — a registered nurse or social worker assigned by the insurer to help plan and arrange care. This is one of the most underused features of LTC insurance.

A care coordinator can:

• Assess care needs and recommend appropriate settings (home care, assisted living, skilled nursing)
• Help find and evaluate licensed providers in your area
• Coordinate the transition between care settings (e.g., from a hospital rehabilitation stay to home care)
• Help complete claims paperwork and communicate with the insurer

There's no additional cost for this service — it's built into the policy. Call your insurer at claim time and ask for care coordinator assignment regardless of whether you think you need help. The insurer's care coordinator works for the insurer, which creates some incentive toward lower-cost options, but for basic coordination services they're genuinely useful.

What a fee-only advisor does here

Most of the claims process is administrative — you work directly with the insurer and the care setting. A fee-only advisor adds value in a few specific ways:

• Claim denial navigation: If a claim is denied, an advisor who understands the policy language can identify the strongest grounds for appeal, help coordinate the right documentation, and in some cases recommend elder law counsel for complex disputes.
• Policy review before care begins: Before a claim is filed, an advisor can review the specific policy terms — covered care settings, qualified providers, how the elimination period counts, reimbursement limits — so there are no surprises when the claim is submitted.
• Coordinating the full funding picture: LTC insurance rarely covers 100% of care costs. An advisor models how policy benefits, Medicare (for skilled nursing), personal assets, and any VA benefits combine — and helps make drawdown decisions (which accounts to tap for cost-sharing) in a tax-efficient order.
• Spousal financial planning during a care event: When one spouse enters a care facility, the other's financial situation changes significantly. Reworking the household budget, adjusting investment allocations, and re-evaluating the surviving spouse's own LTC plan is work that typically happens at claim time, not before.