Denied a long-term care insurance claim? What to do next.

Find three things in the insurer’s letter before anything else.

• What it decided. A first claim refused, or benefits that were being paid and now stop.
• Why. For example the benefit trigger (help with daily activities, or cognitive impairment), the elimination period, or whether the care provider qualifies under the policy.
• The deadline and the address. How long you have to appeal, and where to send it. If the letter doesn’t say, look in the policy: Florida, for example, requires long-term care policies to describe how to appeal benefit decisions.

In several states the time to appeal counts from the day you receive the letter, so write that date down and keep the envelope.

A long-term care policy pays when the insured person meets its benefit trigger: a condition based on their ability to perform activities of daily living and on cognitive impairment. The policy’s own wording decides, so find that page first.

For a tax-qualified policy, federal tax law says who counts as chronically ill: someone certified by a licensed health care practitioner, within the past 12 months, as either

• unable to perform at least 2 activities of daily living without substantial help from another person, for at least 90 days, because of a loss of functional capacity; or
• needing substantial supervision to protect them from threats to health and safety because of severe cognitive impairment.

The six activities are eating, toileting, transferring, bathing, dressing and continence; a tax-qualified policy must take at least five of them into account. Care is provided under a plan of care prescribed by a licensed health care practitioner: a physician, a registered nurse, a licensed social worker, or another person who meets the Treasury’s requirements.

Write to the insurer at the address in its letter, before its deadline. Answer the reason it gave, point by point, and send what supports your answer:

• the care notes or assessment that show which daily activities need hands-on help, and since when;
• a statement from the doctor or nurse who knows the care needed;
• the plan of care, and the invoices for care already given.

Some states set minimum times.

• Montana, Alaska, Oregon, Pennsylvania: 120 calendar days from receiving a benefit-trigger denial to appeal it in writing; the insurer decides within 30 calendar days of having what it needs.
• Iowa: 60 days to appeal a benefit-trigger denial; the insurer decides within 60 days of having what it needs.
• New York: every policy must allow at least 60 days to appeal a first denial; the insurer decides within 60 days, or at most 120 if it is waiting for information it asked you for.
• Washington: the insurer decides within 30 days of receiving the appeal.

If your letter gives a shorter time than these, send the appeal by the letter’s date anyway.

The insurer deals with the insured person unless someone else has standing to act. In the Montana, Alaska, Oregon and Pennsylvania rules, an authorized representative is one of these:

• someone the insured person has given express written consent to represent them;
• someone authorized by law to consent for them;
• a family member or treating health care professional, but only when the insured person can’t give consent.

Ask the insurer whether it wants its own authorization form, and send it with the appeal.

• Independent review. In Montana, Alaska, Iowa, Oregon and Pennsylvania, a benefit-trigger denial the insurer keeps after the appeal can go to an independent reviewer. State by state.
• A complaint to your state’s insurance department. It isn’t an appeal, but the department can help with a complaint against an insurer. California: 1-800-927-4357. Texas: 800-252-3439.
• A lawyer, for anything beyond these. We aren’t lawyers.

We read the insurer’s letter for free and tell you what it says, the deadline it gives and the steps the rules we’ve checked support for your state. Our service that writes long-term care appeals isn’t open yet; “Appeal to the insurer” above shows what to send. We’re not lawyers or public adjusters.