You have a long-term care policy. Why is nothing being paid?
Because a long-term care policy does not pay when care starts. It pays when the insurer agrees three separate things are true, and each one has its own paperwork.
Families are often astonished by the gap between buying the policy and seeing money from it. The person is clearly struggling, care is clearly being paid for, and the insurer is asking for a form nobody has heard of. Nothing has gone wrong. This is how the product works, and knowing the three tests in advance turns a frustrating process into an administrative one.
The three things an insurer has to be satisfied of are: that a benefit trigger has been met, that the elimination period has been served, and that the care being purchased is the kind the policy covers, from the kind of provider it recognises.
What is a benefit trigger?
It is the clinical threshold that switches the policy on. Almost every modern policy uses one of two routes, and meeting either is usually enough.
- Help with activities of daily living. Typically the person must need substantial assistance with two or more of six ADLs, which are conventionally bathing, dressing, toileting, transferring, continence and eating. The number required and the exact list are written into your policy and vary between contracts.
- Cognitive impairment. A severe cognitive impairment requiring substantial supervision to protect the person from threats to health and safety. This route matters enormously in dementia, because someone in the earlier stages may still be physically able to dress and bathe while being entirely unsafe alone.
The phrase to look for is substantial assistance, and it usually has two forms in the contract: hands-on assistance, and standby assistance where someone must be present. Standby counts in most policies. Families routinely under-report because they answer as though only physical lifting qualifies.
Read your own policy for the definitions before anyone completes an assessment form. Answering from a general understanding of the terms, when your contract defines them more generously, is one of the most common reasons a first claim is denied.
What is the elimination period, and does it work in days or in days of service?
The elimination period is a waiting period after the benefit trigger is met, before benefits begin. Ninety days is common, but it can be shorter or longer, and this is where policies differ in a way that has real financial consequences.
- Calendar-day policies count every day once the trigger is met, whether or not care was received that day. These clear faster.
- Service-day policies count only days on which paid, qualifying care was actually delivered. If care is being provided three days a week, a ninety-day elimination period takes roughly seven months of real time to satisfy, not three.
- Some policies waive it for home care, or apply it once per lifetime rather than per claim. Both provisions are valuable and both are easy to miss.
This is the single most important thing to establish early, because the elimination period is paid out of pocket by the family. Knowing whether you are funding three months or seven changes how you plan and, sometimes, how you schedule care.
Whichever kind you have, keep every invoice and every record of the days care was provided from the very first day. Reconstructing this months later, from memory and a bank statement, is miserable and it is the reason claims stall.
Who counts as an approved provider?
This is where home care claims most often fail, and it is worth checking before hiring rather than after.
Many older policies will only reimburse care delivered by a licensed home care agency, and will not pay for a privately hired caregiver at all. Others will pay for an independent caregiver but require them to be certified in a particular way, or exclude anyone who is a family member, or exclude family members who live in the home. Newer policies are frequently broader, and some include care coordination or caregiver training as covered items.
Call the insurer and ask the question plainly: what kind of provider will you reimburse, and what documentation do you need from them? Get the answer in writing. A family that hires an independent caregiver and then discovers the policy required an agency has lost real money for no reason other than sequence.
If you are weighing that choice generally, our guide to hiring privately versus using an agency covers the trade-offs, and a policy requirement may simply settle it for you.
How do you actually file the claim?
The order matters, because several steps run in parallel and the slowest one sets the pace.
- Find the policy and read it. The declarations page gives the daily or monthly benefit amount, the elimination period, the benefit period and whether there is inflation protection. If the policy is lost, the insurer can produce a copy; if the insurer has been acquired or renamed, your state insurance department can help you trace it.
- Call the claims line and open a claim. Ask for the claim packet and ask what the insurer needs from the physician. Write down the claim number and the name of everyone you speak to.
- Arrange the assessment. Most insurers send a nurse assessor to the home, or arrange a telephone assessment. This is the appointment that decides the claim.
- Get the physician's documentation. Insurers usually need a plan of care and supporting clinical notes. A physician who writes 'patient is doing well' in the same month you claim your parent cannot bathe unaided has, without meaning to, undermined the claim.
- Submit provider invoices in the format they ask for, and keep copies of everything.
How do you prepare for the assessment?
The assessment is a snapshot, and it is taken on a single day. That is its weakness and it is what families should plan around.
People with dementia, and older people generally, are very often at their most capable when a professional visitor is in the house. It is sometimes called showtiming. Someone who has not dressed themselves in weeks can rise to the occasion for an hour, answer questions coherently, and leave the assessor with an entirely accurate record of an entirely unrepresentative hour.
- Keep a two-week log before the assessment. Note what help was actually needed, on which days, and for how long. Specific beats general: 'needed physical help stepping into the shower on eleven of fourteen days' is evidence; 'struggles with bathing' is an opinion.
- Be present, and be honest in front of the person. This is genuinely difficult and it is unavoidable. Contradicting your parent in front of an assessor feels like a betrayal; letting an inaccurate picture stand costs them the benefit they paid for over decades.
- Describe the worst days and the average days separately. Assessors are used to this and it is more useful than an average that describes neither.
- Include night-time needs and supervision needs. Cognitive triggers turn on supervision, and supervision is invisible unless you describe it.
What if the claim is denied?
A denial is not the end, and appeal rates are worth knowing about: a meaningful share of denied long-term care claims are overturned when they are properly appealed, because the original denial frequently rests on incomplete information rather than on a genuine failure to qualify.
- Get the denial in writing with the specific reason. A vague denial cannot be answered. Insist on the contractual provision relied on.
- Answer the actual reason. If the denial says one ADL rather than two, the response is documentation about the second ADL, not a letter about how hard things are.
- Ask for an independent reassessment if the assessment day was unrepresentative, and say why, with your log attached.
- Use the free help. Every state has an insurance department that takes consumer complaints about claim handling. Many states also fund free insurance counselling for older adults, and in California that programme is HICAP. Neither charges anything and both are used to these disputes.
- Consider an elder law attorney where the sums are large and the insurer will not move. Many will review a denial without charge.
What else is in the policy that nobody claims?
Beyond the daily benefit, policies frequently contain provisions that go unused simply because nobody reads that far.
- Waiver of premium. Once benefits begin, most policies stop charging premiums. Families sometimes keep paying for months after a claim is approved.
- Care coordination. Many policies fund a care manager to assess needs and build a plan, at no cost to you and often without touching the daily benefit.
- Respite and adult day care are covered by a great many policies and are among the least claimed benefits in the product.
- Home modification and equipment allowances appear in some contracts, usually capped.
- Inflation protection. If the policy has it, the daily benefit today is higher than the figure printed when it was bought. Check the current amount rather than the original one.
Where do you start?
Read the declarations page, call the claims line, and start the two-week log today rather than after the assessment is scheduled. Then arrange the care the policy will actually reimburse.
When you are ready to find that care, The Care Royal lets you search caregivers and agencies by zip code and see what they offer. Searching is free for families. We are a software platform and a marketplace: the agencies and caregivers listed are independent, hiring decisions and background checks are yours or your agency's, and we take no percentage of what you pay.
This is general information about how long-term care insurance policies are commonly structured. Your contract governs, and its definitions differ from these. We cannot give insurance, legal or tax advice; confirm your own position with the insurer, your state insurance department, or a qualified adviser.