Long-term care (LTC) insurance is supposed to help cover the cost of in-home care, assisted living, or nursing home expenses when you can’t fully care for yourself. These policies are meant to offer peace of mind and financial support when families need it most. But here’s the hard truth—many long-term care claims get denied.
When an LTC insurer says no, the effects ripple through a family. Loved ones are left scrambling to pay for care, stress levels shoot through the roof, and policyholders often feel betrayed after years of paying premiums.
If you’ve received a denial letter, you’re not alone—and you’re not out of options. This page explains why these claims are often rejected, what insurance companies don’t want you to know, and what you can do next. For immediate action on your denial, contact a long-term care claim denial attorney near you for a free consultation. They can help fix the problem and fight for the care and benefits you’re owed.
What Are the Most Common Reasons for Long-Term Care Claim Denials?
Insurance companies rarely make the process easy. They often lean on technicalities or use vague policy terms to avoid paying. These are the most common reasons people hear “no” when they file a claim.
Missing Documentation and Paperwork Errors
Even small paperwork mistakes can lead to a denial. Some common issues include:
- Missing physician statements or treatment plans
- Incomplete care provider logs
- Lack of proof for ongoing care needs
If these documents aren’t turned in on time or aren’t detailed enough, the claim can stall or get denied outright. Some insurers give very short deadlines—sometimes just days—to provide this information.
To avoid that, keep careful daily logs of care, collect notes from doctors, and ask for itemized bills from facilities or providers. Submitting a well-organized, complete file gives your claim the best chance of being taken seriously.
Policy Misinterpretation by Insurance Companies
Insurance companies often twist policy language to suit their goals. We’ve seen:
- Definitions of “licensed caregiver” changed mid-claim
- Policies interpreted in ways that limit care locations
In one of our cases, a client’s policy clearly covered in-home care—but the insurer denied payment, saying the caregiver needed a different type of license. After legal review and pressure, we forced them to pay.
These companies use confusing wording to justify cutting off benefits. Don’t assume they’re interpreting the contract fairly.
Failure to Meet the “Activities of Daily Living” Requirements
Most LTC policies require help with at least two “Activities of Daily Living” (ADLs) to qualify for benefits. These include:
- Bathing
- Dressing
- Eating
- Using the toilet
- Transferring (getting in/out of bed or chair)
- Continence
Insurance companies often use unrealistic standards. They may deny claims unless the person is completely unable to do something, even though the policy doesn’t require total dependence.
Keep detailed records from doctors, caregivers, and even family members about how hard these tasks have become. Photos, videos, and written logs can help show how much support is really needed.
Why Do Insurance Companies Routinely Deny Valid Claims?
Insurance companies often deny valid long-term care claims for reasons that go far beyond simple error. These denials usually aren’t just the result of a mix-up or misunderstanding—they’re often built into the company’s process. The system is tilted in the insurer’s favor, and many of the hurdles claimants face are there by design. Below are the leading reasons valid claims get denied again and again.
Profit-Driven Denial Tactics
Insurance companies are businesses. Like any business, they exist to make money. Every dollar paid out on a claim is a dollar off their bottom line. By rejecting valid claims or delaying payment, they hold onto more cash and make shareholders happy.
Here’s how it plays out:
- Delaying payouts keeps money in the insurer’s hands longer, earning interest or investment returns.
- Denying claims outright stops payment completely, forcing some policyholders to pay for care out of pocket or give up altogether.
- Lowball settlements offer less than what’s owed, betting that a policyholder won’t fight back.
Many companies also make the appeal process so frustrating and slow that people eventually walk away. It’s a numbers game, and insurers know that a percentage of claimants won’t pursue it to the end.
Complex Policy Language Designed to Confuse
Most long-term care insurance policies aren’t easy to read. They’re full of:
- Long, technical sentences
- Legal and medical jargon
- Loopholes hidden in fine print
A policy might say it covers care provided in a “licensed facility.” The company then claims the assisted living home isn’t licensed “in the right way” or doesn’t meet an internal checklist. That kind of selective interpretation leads to a denial that isn’t truly based on policy limits—it’s based on wordplay.
Without a legal background or help from someone who knows how to interpret these contracts, it’s easy to miss what’s really being excluded.
Untrained or Biased Claims Adjusters
The person reviewing your claim—called a claims adjuster—plays a huge role in the outcome. Unfortunately, many adjusters:
- Lack of training in assessing long-term care needs
- Use outdated standards that don’t reflect current care practices
- Follow internal scripts that lean toward denial
Some adjusters are under pressure to keep payouts low. Others receive incentives for denying or minimizing claims. This bias shows up in how they:
- Ignore key medical records
- Cherry-pick information that supports a denial
- Dismiss the opinions of your treating doctors
A fair review doesn’t happen when the person in charge already has a goal in mind. If the adjuster is looking for a reason to say no, they’ll usually find one—whether it’s valid or not.
The Bottom Line
Insurance companies have a lot to gain by denying valid long-term care claims. The system often rewards them for saying no, dragging things out, or burying you in paperwork. Policy language is crafted to confuse. Claims adjusters may not fully understand the care needs involved—or worse, they may be coached to dismiss them.
Understanding this pattern is the first step to fighting back. You don’t have to accept a wrongful denial as the final answer. If you’ve been told no, it doesn’t mean your claim isn’t real—it often means the insurer is betting you’ll walk away. Don’t give them that satisfaction. Contact an attorney today to hold them accountable.
What Should You Do Immediately After Receiving a Denial?
You don’t have to accept the denial. But timing and preparation matter.
Review the Denial Letter Carefully
Start by reading the denial letter top to bottom. Look for:
- The specific reason for denial
- Policy sections the company cites
- Dates, provider names, and other details
You’re looking for holes in their reasoning—something that doesn’t add up. If they say you didn’t send a document, but you have proof you did, that’s valuable. Take notes on anything that feels off.
Gather Additional Supporting Documentation
Next, gather more evidence to support your claim. This might include:
- Updated medical reports or physician statements
- Caregiver logs showing frequency and type of help needed
- Functional assessments from physical or occupational therapists
Opinions from neutral medical professionals can carry a lot of weight. So can daily care logs that show a pattern of assistance.
Consider Whether to File an Appeal
Some LTC policies give you 30 to 180 days to appeal, and others don’t even provide for an appeals process. An LTC policy could have a mandatory arbitration provision or other choice of law considerations. In our experience, the insurance company will offer you an appeals process no matter what the policy provides. Whether or not to appeal is a case-specific consideration that depends on the policy, claims handling, governing law, medical evidence, and more. You should get legal advice at this juncture if you have not already.
If you do appeal, you should consider providing information such as:
- An explanation of why the denial is wrong
- Supporting documents to support why the claim should be paid
Mistakes to avoid:
- Sending the same documents again without changes
- Missing deadlines
- Writing an emotional letter without facts to back it up
Legal help at this stage can change the outcome.
How Can an Experienced Attorney Improve Your Chances of Approval?
Insurers don’t treat everyone the same. They react differently when they see a legal team on the other side.
Legal Interpretation of Policy Language
Attorneys trained in insurance law know how to break down confusing policies. They can:
- Find clauses that support your claim
- Push back on inaccurate interpretations
- Cite previous court rulings that favor the policyholder
Many claims get approved simply because someone showed the company they weren’t bluffing.
Professional Communication with Insurance Companies
Letters from attorneys often get quicker responses. Legal teams know:
- Which department to contact
- Who has decision-making power
- How to apply pressure using deadlines and regulations
They also understand the games insurers play—and how to call them out.
Litigation Options When Appeals Fail
When appealing is not the best path forward or fails to get the claim approved, legal action may be the only way forward.
Your attorney might pursue:
- Breach of contract claims
- Breach of the covenant of good faith and fair dealing (bad faith)
- Fraud or misrepresentation claims
- Claims against other culpable parties for aiding and abetting
- Intentional infliction of emotional distress
- Statute-specific claims, statutory penalties, or state law consumer protection claims
Statistics about Social Security Disability Insurance (SSDI) benefits reveal that claimants with legal representation tend to recover more than those who represent themselves. These findings may also apply to long-term disability (LTD) and long-term care (LTC) claims.
What Legal Remedies Exist Beyond the Standard Appeals Process?
Some cases go beyond a simple appeal. Legal remedies can bring more pressure—and sometimes more money.
Bad Faith Insurance Claims
Insurers must act in good faith and deal fairly with policyholders. If an insurer acted unfairly or dishonestly, you may have a bad faith claim.
Bad faith can involve:
- Unreasonable Delay in Payment or Claims Investigation
- Denying Claims Without a Reasonable Basis
- Misrepresentation of Policy Terms
- Undervaluing or Lowballing Claims
- Failure to Acknowledge or Respond to Communications
Punitive damages are designed to punish and deter egregious misconduct. If proven, you could recover extra damages beyond your original claim meant to deter the insurer’s conduct in future claims.
How Our Firm Can Help You Fight Back
At Sandstone Law Group, we know how insurance companies operate. We’ve handled hundreds of long-term care denials and helped our clients recover the benefits they paid for.
Here’s how we work:
- Initial Case Review: We’ll look at your policy, your denial letter, and your documentation—for free.
- Evidence Building: We help gather the strongest possible file with support from doctors, care providers, and specialists.
- Strategic Response: We plan each step to apply pressure and hold the insurance company accountable.
Fee Structure and Client-First Policy
We work on a contingency fee basis. That means:
- You pay nothing upfront
- We only get paid if we recover money for you
- Our interests stay aligned with yours
We also promise clear, consistent updates. You’ll never be left wondering where things stand.
Contact Our LTC Denials Lawyers Now
Appeals don’t last forever. Deadlines tick away fast after a denial, and every day matters.
Sandstone Law Group has the experience, tools, and record of success you need on your side. We’ve helped countless families recover the care they were promised—and we’re ready to help you too.
Your policy should protect you, not frustrate you. Let us review your case, explain your rights, and tell you how we can help.
Call 602-615-0050 now or fill out our online form for a free, no-obligation case review. Don’t let the insurance company keep what you’ve rightfully earned.
At Sandstone Law Group, we stand by our clients every step of the way—and we don’t stop until the job is done.
