Receiving a denial letter for long-term care insurance (LTCI) benefits is devastating. You planned ahead. You paid your premiums. Now, when care is needed most, the insurance company is refusing to honor the policy you relied on.
Insurers often deny legitimate LTCI claims by narrowly interpreting Activities of Daily Living (ADLs), minimizing cognitive impairments, or hiding behind vague policy terms. They rely on one-time assessments, biased evaluations, and bureaucratic obstacles to avoid paying what they owe. For many families, the process becomes exhausting.
We understand how high the stakes are. These benefits are meant to provide dignity, safety, and peace of mind at a vulnerable time. Our attorneys are experienced in confronting long-term care insurers who use delay and denial tactics to protect their profits instead of their policyholders.
If your claim has been denied, delayed, or underpaid based on questionable ADL assessments or cognitive evaluations, this is not the time to go it alone. These insurers know exactly how to make the process difficult. We know exactly how to fight back.
What Are Activities of Daily Living (ADLs)?
To receive benefits under an LTCI policy, most insurers require proof that you are unable to independently perform at least two ADLs, or that you suffer from a severe cognitive impairment that makes it unsafe for you to manage basic daily tasks on your own.
These ADLs are not complex medical procedures; they are the essential, everyday actions that allow people to live independently. Unfortunately, insurance companies often use vague definitions and narrow interpretations of these tasks to deny legitimate claims.
The Commonly Recognized ADLs Include:
- Bathing: The ability to wash yourself, including getting in and out of a bathtub or shower.
- Dressing: Being able to select appropriate clothing and put it on, including the ability to manage buttons, zippers, and supportive devices.
- Toileting: Getting to and from the toilet, using it properly, and cleaning oneself afterward.
- Continence: The ability to control bladder and bowel function, or to manage devices like a catheter or colostomy bag.
- Transferring: Moving in and out of a bed, chair, or wheelchair without assistance.
- Eating: The ability to feed oneself, not to be confused with cooking or meal preparation.
- Ambulating (in Non-tax qualified policies): Walking or otherwise moving independently from one place to another.
If you cannot do two or more of these tasks safely or without help, or if cognitive decline makes it unsafe to be alone without substantial supervision, you likely meet the criteria for long-term care benefits.
Yet despite clear struggles, many people are wrongfully denied coverage because an insurer claims they are still capable of managing their ADLs. Often, this decision is based on a short, one-time assessment or a surface-level review of paperwork, not the reality that family members and caregivers see day in and day out.
What Is Considered a Severe Cognitive Impairment?
Not all long-term care needs are physical. Many policyholders require supervision and support due to mental decline, which is just as serious—and just as valid—as physical limitations. In fact, severe cognitive impairment is an independent qualifying condition under most long-term care insurance (LTCI) policies.
Cognitive impairment refers to loss in memory, reasoning, judgment, or the ability to recognize people, places, or time. This type of deterioration is commonly caused by:
- Alzheimer’s Disease
- Other forms of dementia
- Brain injuries or neurological disorders
- Serious mental illness
- Stroke or brain tumor complications.
Someone suffering from severe cognitive impairment may still be physically able to perform daily tasks like eating or walking. However, if they lack the awareness, memory, or judgment to do these tasks safely, they are functionally incapable of living independently and qualify for care under most LTCI policies.
For example:
- A person with dementia might forget how to use a stove, increasing the risk of a house fire.
- They might leave the home and wander, unable to find their way back.
- They might forget to take essential medications or take them multiple times.
In these cases, supervision or structured assistance becomes necessary, not because of physical frailty, but due to mental vulnerability.
Unfortunately, insurance companies often downplay cognitive impairment, or try to misconstrue tests like mini-mental status examinations. But cognitive decline is progressive and dangerous. That is why LTCI policies typically consider “substantial supervision” a qualifying level of care, even if the insured can technically still bathe or dress on their own.
If your loved one is being denied LTCI benefits based on a misinterpretation of their cognitive condition, it is time to fight back. These denials are not just wrong, they are unlawful. Sandstone Law Group stands ready to hold insurers accountable and secure the care your family deserves.
The ADL Assessment Process
Filing an LTCI claim is often not as simple as letting your insurance company know you need help. Instead, policyholders and their families are often put through a layered and often frustrating assessment process designed to verify eligibility.
Filing Your Claim
The process typically starts when the policyholder, or, more often, a family member or caregiver, notifies the insurance company that long-term care services are needed. The insurer may request supporting documentation, such as:
- Medical records, such as hospital notes, physical therapy reports, and diagnoses
- A Chronically Ill Certification (CIC) from a licensed healthcare provider.
- PAQ or Insured Forms: You may need to complete forms about your needs. Do not hesitate to attach additional pages explaining your needs and functionality, as these forms are often deceptively written and too generalized.
At this stage, it is critical to be thorough and precise. Vague or incomplete submissions can open the door for delays or denials down the line.
The Insurer’s Evaluation
Once the claim is opened, the insurance company will usually send a licensed healthcare professional, such as a nurse or occupational therapist, to evaluate the insured in what is referred to as a Benefit Eligibility Assessment (BEA). This can be done in person or, increasingly, via a virtual visit.
Despite what the insurer may imply, this evaluator is not an independent advocate; they are either contracted by the insurer or are an in-house medical professional employed by the insurance company, and their reports often lean in favor of minimizing your needs.
The evaluator uses a standardized form to determine whether you need substantial assistance with two or more ADLs. Assistance can be categorized as:
- Hands-on assistance: Physical help completing the task (e.g., helping someone into the shower)
- Standby assistance: Being present to prevent harm, offer verbal cues, or intervene if needed (e.g., someone who forgets the steps involved in toileting or bathing)
Insurers often attempt to downplay standby assistance as insufficient, even when it is clear the individual cannot function safely without it.
Assessment of Each ADL
The evaluator will examine your ability to perform each ADL, either through direct observation or by asking questions. They are supposed to consider:
- How often the person has difficulty
- The type and level of help required
- Any safety risks, such as falls, confusion, or wandering.
Evaluators may also ask about Instrumental Activities of Daily Living (IADLs), which are activities like managing finances, preparing meals, or driving. While relevant to a person’s overall care picture, IADLs do not trigger LTCI benefits, and insurers are not supposed to base approval or denials on these.
Cognitive Evaluation (If Needed)
If the policyholder does not appear to meet the ADL threshold but shows consistent signs of memory loss or mental decline, the insurer may conduct a cognitive impairment assessment.
This often includes standardized tools like the:
- Mini-Mental State Exam (MMSE)
- Montreal Cognitive Assessment (MoCA).
The goal is to determine whether the person suffers from severe cognitive impairment such that they require substantial supervision because the individual cannot make safe decisions, recognize hazards, or adequately understand their surroundings. Even if a person can bathe or dress themselves, severe cognitive impairment alone may qualify them for LTCI benefits.
Insurance Company Review
After the evaluation, the insurance company will review all submitted documentation, including:
- The assessor’s report
- Medical records
- Physician certifications
- Any forms completed by the insured.
Denials often occur at this stage, even when everything appears in order. Insurers may claim the person does not meet the ADL threshold or is not “chronically ill” enough under the policy definition.
Red Flags in an ADL Assessment
Here are some signs that the insurer may be gearing up to deny or delay your LTCI claim based on ADL findings:
- The nurse spent only a few minutes observing each task.
- The report contradicts your physician’s notes.
- The insurer insists you need only “standby” help, not “hands-on.”
- The report uses language like “mild,” “intermittent,” or “occasional” to minimize your limitations.
- You receive a denial with no clear explanation or vague references to policy definitions.
How to Strengthen Your ADL Claim
Review Your Policy Carefully
Understand what “chronically ill” means under your policy. What does it say about ADLs? How many must be impaired? Is cognitive impairment listed?
Get Legal Help Early
LTCI cases can be won or lost based on how claims are submitted. Working with experienced Long-Term Care Insurance Denials attorneys like those at Sandstone Law Group can drastically increase your chances of approval. Knowing the law and state-specific statutes and requirements can give you an advantage in the long-term care claims process.
Keep a Daily Care Journal
Track your daily needs. Who helps you bathe? Dress? Eat? Write it down. This log can be one of the most powerful tools in your case.
Submit Detailed Physician Records
Include notes, test results, and treatment summaries. Make sure your doctor’s records align with the LTCI claim forms.
Ask for a Second Opinion and get your own Chronically Ill Certification
If the insurer sends a nurse who downplays your condition, get your own evaluation. A private occupational therapist or geriatric specialist may give a more accurate assessment. Also, take the initiative and get a chronically-ill certification (CIC) from your provider.
Elimination Periods
If the insurer decides that the policyholder qualifies, they will issue a benefits approval, often with a catch. Many policies include an elimination period.
An elimination period is the amount of time you must wait after becoming eligible for benefits before your policy actually starts paying. It functions similarly to a deductible in health insurance, but instead of paying a fixed dollar amount, you are paying with days of unpaid care.
Common elimination periods are 30, 60, or 90 days, though some policies begin coverage immediately if you pay a higher premium. This period only begins after the insured meets the policy’s benefit triggers (being unable to perform two or more ADLs or being diagnosed with a severe cognitive impairment).
Not all elimination periods are the same. Insurers use different methods to calculate them, and the fine print can drastically affect how soon benefits are paid:
- Calendar-Day Elimination Period: Starts counting from the day you begin needing care, regardless of how often you receive it. If you become eligible on March 1 and your policy has a 30-day elimination period, benefits would begin on March 31, assuming all requirements are met.
- Service-Day Elimination Period: Only counts the days you actually receive care. If you get in-home care three times a week, it could take 10 weeks or more to satisfy a 30-day elimination period. This is a common trap that leads to long delays in payment.
- Dollar-Based Deductibles: Some policies substitute a dollar amount in place of a time-based waiting period. In those cases, the policy starts paying after you have paid a certain amount out-of-pocket for covered services.
Many policies exclude care provided by family members from counting toward the elimination period, even if that care is extensive and necessary. Others may require the elimination period to be satisfied within a specific timeframe or even met more than once if care needs arise at different times.
Contact Sandstone Law Group Today
ADL assessments should help long-term care policyholders get the care they deserve. But in reality, insurers have twisted the process into a tool that serves their bottom line.
At Sandstone Law Group, we see through these tactics, and we fight back. If your claim was denied, delayed, or underpaid based on a questionable ADL assessment, it is time to speak with an experienced LTC insurance lawyer.
Let us help you take the fight to the insurer and reclaim the benefits you paid for. Contact Sandstone Law Group at (602) 615-0050. You do not have to accept the insurer’s version of your reality.