You Have a Long-Term Care Insurance Policy — Now What?

What triggers a payout

Most policies pay once a licensed health care practitioner certifies that the person needs substantial help with two of six daily activities — bathing, dressing, toileting, transferring, continence, or eating — expected to last at least 90 days, or has a severe cognitive impairment like dementia. This isn’t just a doctor’s note: the insurer typically sends its own nurse to do a functional assessment before approving the claim.

The elimination period — the part people misunderstand

This is the policy’s waiting period — commonly 30, 60, or 90 days — before benefits start, and the family pays out of pocket during it. The trap: check whether the policy counts calendar days or service days. A 90-calendar-day period is satisfied three months after care starts, no matter what. A 90-service-day period only counts days care was actually received — with home care three times a week, that can stretch a “90-day” wait into roughly seven months. Read the policy’s own definition before budgeting around it.

What the claim actually requires

1. A notice of claim to the insurer (call the claims line, not the original sales agent).
2. Physician certification plus the insurer’s own nursing assessment.
3. A plan of care — most insurers won’t pay without this document on file, and it’s often required to be updated periodically.
4. Ongoing, itemized invoices from a licensed provider to trigger reimbursement, typically submitted monthly.

Common reasons claims get denied or delayed

• Care received in an unlicensed setting or from an informal, unlicensed caregiver.
• Skipping the plan-of-care step and expecting reimbursement anyway.
• Filing before the elimination period is actually satisfied, especially with a service-day policy.
• The actual cost of care exceeding the policy’s daily or monthly benefit cap — the difference is the family’s responsibility, and the benefit pool depletes faster than expected as a result.