Before You File: What to Know First
Long-term care insurance claims are more complex than most other insurance claims. The process involves multiple parties — the insured, the family, the treating physician, the care facility, and the insurer's own care assessor — and typically takes 4 to 8 weeks from initial notification to first benefit payment. Understanding the process before you begin significantly reduces the risk of delays and denials.
4–8 weeks
typical time from initial notification to first benefit payment
30–60 days
recommended advance notice to insurer before care starts
2 of 6 ADLs
minimum ADL impairment required to trigger benefits (tax-qualified policies)
The 8-Step LTC Insurance Claim Process
Each step below includes a checklist of specific tasks. Click a step to expand it and check off tasks as you complete them.
Find the original policy document — check filing cabinets, safe deposit boxes, or ask the insurance company for a copy using the policy number. Read the full coverage section, paying close attention to: benefit triggers (the conditions that must be met to receive benefits), the elimination period (the waiting period before benefits begin), the daily or monthly benefit amount, the benefit period (how long benefits will last), and the types of care settings covered (home care, assisted living, memory care, nursing home). If you cannot find the policy, contact your state's insurance department — they maintain records of policies issued in the state.
Step 1 Checklist
Document Tracker
Use this tracker to ensure you have gathered all required and recommended documents before submitting the claim. Incomplete submissions are a leading cause of delays.
| Document | Category | Required | |
|---|---|---|---|
| Original policy document | Policy | Required | |
| Policy number and insurance company contact information | Policy | Required | |
| Completed insurer claim forms | Forms | Required | |
| Physician certification of ADL impairment or cognitive impairment | Medical | Required | |
| Medical records supporting diagnosis and functional status | Medical | Required | |
| Care plan or assessment from treating physician or care manager | Medical | Required | |
| Facility state license (if care is in a licensed facility) | Facility | Required | |
| Copy of residency agreement or home care contract | Facility | Required | |
| Facility or agency tax identification number | Facility | Required | |
| Records of care expenses during elimination period (with receipts) | Financial | Required | |
| Monthly invoices from care provider (for reimbursement policies) | Financial | Required | |
| Direct deposit banking information | Financial | Recommended | |
| Prior authorization or pre-certification (if required by policy) | Forms | Recommended | |
| Power of attorney or legal authorization (if filing on behalf of insured) | Legal | Recommended | |
| Copy of insurer's care assessment report | Medical | Recommended |
How to Get a Strong Physician Certification
The physician certification of benefit triggers is the most critical document in the claims process. Vague or insufficient certifications are among the most common reasons claims are delayed or denied. The following guidance helps ensure the certification is as strong as possible.
Be specific about ADL impairments
Vague language such as 'needs some help with bathing' is less effective than 'requires hands-on assistance to enter and exit the shower safely due to balance impairment and lower extremity weakness.' Specific, clinical language is more persuasive to the insurer's reviewers.
Document the expected duration
For the ADL trigger, the insured must be expected to need assistance for at least 90 days. The physician must certify this expectation explicitly. If the physician is uncertain, ask them to document the clinical basis for their expectation.
Use the insurer's certification form
Most insurers provide their own physician certification form. Use this form rather than a generic letter — it is designed to capture the specific information the insurer needs and reduces the risk of missing required elements.
Prepare the physician in advance
Before the appointment, prepare a written summary of the specific ADL impairments or cognitive deficits you have observed at home. Physicians often see patients at their best during office visits; your observations of day-to-day functioning are essential context.
Request a copy of the certification
Ask the physician for a copy of the signed certification before it is submitted to the insurer. Review it for accuracy and completeness. If anything is missing or unclear, ask the physician to revise it before submission.
Consider a geriatric assessment
If the physician is not familiar with the insured's day-to-day functioning, a formal geriatric assessment by a geriatrician or geriatric care manager can provide a more detailed and clinically credible picture of functional status.
Why Claims Are Denied and How to Appeal
Long-term care insurance claims are denied more frequently than most families expect. Understanding the most common denial reasons — and how to respond — significantly improves the likelihood of a successful appeal.
Appeal Timeline
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