A long‑term care insurance denial can feel overwhelming. You purchased coverage to protect yourself and your family, years before you ever needed it. You paid premiums, trusted the insurer, and expected support if your health prevented you from performing your activities of daily living or cognitive decline caused you to require constant supervision.

If this has happened to you, you are not alone. Insurance companies deny claims for many reasons, and some of those reasons are not fair, not accurate, or not supported by the policy. The good news is that a denial is not the end of the road. You have options, and you can challenge the decision.

This guide explains why claims are denied, what steps you should take, and how to protect your rights.

Why Long‑Term Care Claims Are Denied

Long‑term care insurance is designed to provide financial support when you can no longer perform certain daily activities independently or when you require supervision due to cognitive decline. These benefits are intended to provide financial protection in the event that you need substantial assistance with your personal care or even to pay the cost of a long term care facility. Despite this, insurers frequently deny claims. Common reasons include:

1. The insurer says you do not meet the “activities of daily living” (ADL) criteria

Most policies require that you be unable to perform at least two ADLs without substantial assistance. These typically include:

• Bathing
• Dressing
• Eating
• Toileting
• Transferring
• Continence

Insurance providers will interpret these criteria narrowly. For example, they may argue that you can technically dress yourself, even if doing so is unsafe, painful, or requires significant time and effort.

2. The insurer disputes cognitive impairment

For individuals with dementia, Alzheimer’s disease, or other cognitive conditions, insurers may claim:

• Your cognitive impairment is not severe enough to require assistance
• You do not require supervision
• Your doctor’s assessment is insufficient

These disputes are common, even when family members and caregivers see clear evidence of decline.

3. The insurer claims the care you receive is not “eligible”

The insurance company may suggest that the policy requires care to be:

• Provided by a licensed provider
• Delivered in an approved setting
• Consistent with a care plan

Insurers may deny claims if care is provided by family members in your own home, if the facility is not recognized by the policy, or if the care plan is not updated regularly. It is important to review your policy and see whether the policy allows the insurer to deny the claim on this basis. It is entirely possible that the level of care being provided is sufficient to satisfy the policy’s terms.

4. The insurer says your condition is “not severe enough”

This can be a subjective assessment. Insurers may rely on their own evaluators, who often spend very little time with you and may not understand your day‑to‑day challenges.

5. Missing or incomplete documentation

Even minor paperwork issues can trigger a denial. Insurers require documentation, and any gaps can be used as justification to refuse benefits.

What To Do Immediately After a Denial

A denial letter is upsetting, but it is also a roadmap. It tells you exactly why the insurer refused your claim and what evidence they believe is missing. Here are the steps you should take right away.

1. Read the denial letter carefully

Look for:

• The specific reason for the denial
• The policy language the insurer is relying on
• Any deadlines for appeal
• Any documents the insurer says are missing

Do not assume the insurer’s interpretation is correct. Many denials are based on misreading or misapplying the policy.

2. Request a complete copy of your policy

You are entitled to:

• The full policy
• All riders and amendments
• Any underwriting notes
• Any internal guidelines used to assess your claim

You can evaluate the denial if you learn the terms of your coverage by reviewing the policy and determine what the case manager considered by reviewing your claim file.

3. Gather medical and care documentation

This may include:

• Physician notes
• Occupational therapy assessments
• Cognitive testing
• Caregiver logs
• Facility care plans
• Hospital records

The goal is to build a clear picture of your functional limitations and care needs.

4. Ask your doctor for a detailed letter

A strong medical letter should:

• Describe your diagnosis
• Explain your functional limitations
• Identify which ADLs you cannot perform independently
• Confirm whether you require supervision
• Outline the type and frequency of care you need

Insurers give significant weight to medical opinions, especially when they are clear and specific.

5. Document your daily challenges

Your lived experience matters. Keep a written record of:

• Tasks you cannot perform safely
• Times when you require assistance
• Cognitive lapses or safety concerns
• Caregiver involvement

This documentation can be powerful evidence during an appeal.

6. Do not miss appeal deadlines or the limitation period

Most policies have strict timelines for internal appeals. Missing a deadline can limit your options. More importantly, a limitation period will prevent you from starting a lawsuit to challenge the decision. If you are unsure about timing, seek legal advice immediately.

How to Strengthen Your Appeal

A successful appeal is built on evidence, clear communication, and a strong understanding of the policy. Here are strategies that can make a significant difference.

1. Address the insurer’s reasons directly

If the insurer says you can perform certain ADLs, provide evidence showing why that is not accurate. If they dispute cognitive impairment, include updated testing or assessments.

2. Provide third‑party assessments

Occupational therapists, physiotherapists, neuropsychologists, and geriatric specialists can provide objective evaluations that can persuade the insurer.

3. Ensure your care plan is up to date

If you receive home care or live in a facility, ask for:

• Updated care plans
• Progress notes
• Safety assessments

These documents show the level of support you require.

4. Challenge insurer‑funded assessments when appropriate

Insurer assessors may:

• Spend limited time with you
• Rely on checklists rather than functional observation
• Understate your limitations

You are entitled to provide your own independent assessments.

5. Seek legal advice early

Long‑term care insurance policies are complex, and insurers often rely on technicalities to deny coverage. A lawyer can:

• Interpret the policy
• Identify errors in the denial
• Gather the right evidence which shows that you satisfy the eligibility criteria
• Communicate with the insurer
• Prepare a strong appeal

Early involvement can prevent delays and strengthen your position.

When to Consider Legal Action

If the insurer refuses to overturn the denial after an internal appeal, you may need to consider legal action. Starting a lawsuit rarely means you will have to go to court. Many cases resolve through negotiation or mediation once the insurer sees that you have persuasive medical evidence and effective legal representation.

Legal action may be appropriate if:

• The insurer misinterprets the policy
• The denial contradicts medical evidence
• The insurer relies on flawed assessments
• There are unreasonable delays
• The insurer acts in bad faith

A lawyer can help you determine the best path forward to gain access to your long term care benefits.

Final Thoughts

A long‑term care insurance denial is stressful, but it is not final. Some denials are overturned once the insurer is presented with clear evidence, updated assessments, and specific reference to the policy. You do not need to navigate this process alone. With the right support, you can challenge the decision and secure the benefits you paid for and deserve.

For advice, please text 613-777-0992 or contact us to schedule a meeting with one of our lawyers.  We will provide a free consultation, in French or English, to ensure that your rights are protected.   In most cases, we can offer to represent you on a contingency fee basis.  This means that you do not pay legal fees unless you win or achieve a settlement on your case.