What You Need to Know About Long-Term Care Insurance Policies Before Filing a Claim

Filing a long-term care (LTC) insurance claim should be a straightforward process, especially after years—or even decades—of paying premiums. But for many policyholders and their families, the reality is far more complicated. Long-term care policies are dense with technical language, hidden requirements, and strict documentation rules. Filing a claim without a thorough understanding of your policy could delay approval or result in an outright denial.

At Disability Insurance Law Group, we work with clients nationwide to help them prepare strong, successful claims. Here’s what you need to know before you file.

Understand What Long-Term Care Insurance Covers

Long-term care insurance is designed to pay for services not typically covered by health insurance or Medicare. These services include assistance with daily activities due to illness, injury, or cognitive impairment. But coverage varies widely from one policy to another.

Before filing a claim, clarify whether your policy covers:

• In-home care services, and if the caregiver must be licensed.
• Assisted living or nursing home stays.
• Adult day care or hospice care.
• Home modifications or durable medical equipment.

Be aware: Some policies only provide benefits if care is delivered in specific types of licensed facilities. Others require that the insured receive prior hospitalization or meet other preconditions. Understanding what your policy includes is essential before seeking care.

Know the Activities of Daily Living (ADL) Requirement

Most long-term care insurance policies require proof that the policyholder is unable to perform at least two out of six activities of daily living (ADLs) without assistance.

These ADLs include:

• Bathing
• Dressing
• Eating
• Toileting
• Transferring, including from bed to chair.
• Continence.

Alternatively, a diagnosis of severe cognitive impairment—such as Alzheimer’s disease—may also qualify.

Important: It’s not enough to say that you need help. Your physician must document the limitations in a way that aligns with your policy’s definitions. Many claims are denied simply because the medical records don’t use the insurer’s required terminology.

Be Prepared for the Elimination Period

An “elimination period” refers to the waiting period before benefits begin, typically ranging from 30 to 180 days. During this time, you’re required to pay out-of-pocket for qualifying care. However, the clock usually does not start until the insured is receiving services that meet the policy requirements.

To avoid costly delays:

• Ensure that care is provided by a licensed caregiver or facility, if necessary.
• Keep detailed records of services rendered.
• Confirm that the care you receive satisfies the policy’s definitions of coverage.

Gather Proper Documentation Before You File

Insurance companies often deny claims due to “insufficient evidence.” Don’t give them the opportunity. Prepare your file thoroughly before submitting your claim.

You should include:

• Medical records and recent physician notes.
• A physician’s statement describing ADL limitations or cognitive decline.
• Caregiver or facility licensure documents.
• Invoices or receipts for services provided.
• Any required forms or claim packets from the insurer.

Why Legal Guidance Can Make a Difference

Even well-meaning families can make honest mistakes when navigating these complex policies. A single missed definition, vague doctor’s note, or incorrectly timed care can derail an otherwise valid claim.

At Disability Insurance Law Group, our experienced attorneys review policies, guide clients through documentation, and help families file complete and persuasive claims. Before filing, please contact us at 954-989-9000 or online for a complimentary consultation. We’re here to protect your rights—and help you access the care and benefits you’ve paid for.