Case Result

A long-term care insurance policy is purchased so care costs can be covered when they become necessary. When a claim is denied, families are forced to manage immediate care expenses while also challenging a decision that is often driven by benefit triggers and documentation, not a clear statement that coverage does not apply. A denial frequently reflects the insurer’s position that the record does not establish eligibility under the policy terms or that it limits what it will pay as benefits owed.

Step one is understanding what the policy requires

Long-term care insurance is generally designed to cover the cost of care assistance with activities of daily living. Many policies use benefit triggers, meaning conditions that must be met before benefits become payable. A common trigger is the inability to perform two of six activities of daily living, or a severe cognitive impairment. 

The 6 core ADLs include:

• Bathing and Hygiene: Washing, drying, and grooming.
• Dressing: Selecting clothing and physically putting it on.
• Eating: The physical act of moving food from a plate to the mouth and swallowing.
• Transferring: Moving oneself from one position to another, such as getting out of bed or standing up from a chair.
• Toileting: Getting on and off the toilet.
• Continence: The physical ability to control bladder and bowel functions.

This matters because claim denials are often framed around those triggers. The insurer may claim the insured can still perform enough activities independently, or it may claim the documentation does not show a qualifying level of limitation. If the claim is going to be challenged, it has to be challenged on the policy’s terms, not on general frustration with the decision.

Step two is building a clean, organized record

Insurers often deny or delay claims based on what they say is missing. That can include incomplete physician notes, insufficient functional detail, or gaps between reported symptoms and recorded limitations. A strong claim file usually requires:

• Medical records that document limitations over time
• Physician documentation that addresses functional ability, not only diagnoses
• Care notes that show what assistance is required and how often
• Consistent reporting that aligns with the policy’s activities of daily living requirements

Long-term care disputes often come down to functional detail. General statements about pain or weakness may not be enough if the records do not clearly document what the insured can and cannot do and what assistance is needed day to day. Policies may also include an elimination or waiting period before benefits begin, so incomplete or unclear documentation can give an insurer room to argue that benefits were not triggered for a specific timeframe, which is why a complete record helps reduce ambiguity.

Step three is identifying whether the denial may involve bad-faith conduct

Some denials are simple disagreements over documentation. Others may indicate a larger problem in how the claim was handled. Insurers may issue improper denials, including when companies underpriced policies and later attempt to limit claim payouts.

The point is not to assume wrongdoing in every denial. The point is to evaluate how the insurer reached its decision and whether it considered the full record.

In California, a wrongful denial can involve more than breach of contract. An insured may assert a claim for breach of the implied covenant of good faith and fair dealing, commonly referred to as insurance bad faith. This becomes relevant when the claim handling behavior, not only the outcome, is part of the dispute.

Step four is using the legal process to force a full review

Some insurers do not meaningfully reconsider a long-term care denial until the dispute is pursued through formal legal channels. Litigation can create a structured process for obtaining the insurer’s claim handling file, internal documentation, and the stated basis for the denial, which may clarify what was considered and what was ignored. That additional information can change how the dispute is evaluated and can affect whether the matter resolves through settlement or proceeds further.

Step five is staying focused on what matters most

Long-term care disputes can become technical quickly. The most effective approach is usually disciplined and specific:

• What does the policy require
• What does the medical and care record show
• What did the insurer rely on
• What evidence was ignored or minimized
• What can be proven clearly through documentation and expert support when needed

Long-term care insurance is meant to pay for assistance with daily living. When an insurer denies a claim that should be covered, the dispute is not academic. It affects care decisions, family capacity, and the ability to maintain stability. Fighting back means forcing a decision that is grounded in the policy language and the evidence, not an insurer’s preferred narrative.

A closing note on Donahue & Horrow’s approach

Donahue & Horrow LLP’s long-term care practice emphasizes compassion, organized documentation, clear evaluation of benefit triggers, and readiness to litigate when an insurer refuses to honor the policy. 

If your long-term care insurance claim was denied, the next step is often a structured review of the denial rationale, the policy’s benefit triggers, and the existing medical and care record. Donahue & Horrow LLP represents policyholders in long-term care disputes and works to secure the benefits owed under applicable policies. Call 877-664-5407 for a free consultation.