Long-Term Care Insurance: How to Use a Policy You Already Have

Long-term care insurance policies are often paid for decades and then mishandled when the time comes to use them. Claims are delayed, filed incorrectly, or denied on technicalities. This guide is for families who already have a policy and want to activate it correctly.

What Triggers a Claim

Every LTCI policy has specific benefit triggers. Most policies use one or both of:

Activities of Daily Living (ADL) triggers: Coverage begins when the insured can no longer perform a specified number of ADLs — typically 2 out of 6 — without substantial assistance. The six ADLs are: bathing, dressing, eating, toileting, continence, and transferring.

Cognitive impairment trigger: Coverage begins when the insured has a cognitive impairment — typically dementia — that requires substantial supervision for health or safety. This trigger is separate from ADL requirements — cognitive impairment alone can qualify.

The Elimination Period

Almost all LTCI policies have an elimination period — a waiting period before benefits begin, typically 30, 60, 90, or 180 days. The clock typically starts when the person begins receiving qualifying care. Review your policy to understand exactly when it begins and what counts toward satisfying it.

How to File the Claim

1. Notify the insurer immediately — contact the claims department as soon as possible.
2. Request claim forms — the insurer sends attending physician’s statement, functional assessment, and provider forms.
3. Get the physician’s statement completed thoroughly — vague statements are a common reason for delays or denials.
4. Complete the functional assessment — many insurers require their own nurse to conduct a home visit. Present a realistic account of your loved one’s worst days, not their best.
5. Submit provider documentation — care agencies submit invoices directly.
6. Track everything — copies of all submissions, dates, names of everyone spoken to.

Common Reasons for Denials

Insufficient documentation of ADL limitations. Care that doesn’t meet policy definitions (some require licensed agency, not a privately hired caregiver). Waiting period not properly documented. Policy exclusions in older policies.

If Your Claim Is Denied

Request a written explanation. File a formal appeal through the policy’s appeal process. Contact your state insurance commissioner if the appeal fails. An elder law or insurance attorney can assist with complex appeals.

Ask Danny

Danny says: LTCI claims are one of the areas where families leave significant money on the table — either by not knowing to file or by having claims denied for fixable reasons. Tell me about the policy and where you are in the process, and I can help you think through the next steps.

Talk to Danny → Help me understand my LTCI policy and file a claim What do I do if my LTCI claim was denied?

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