Long-Term Care Insurance Appeal

Purpose

This template provides a comprehensive framework for appealing the denial of a long-term care insurance (LTCI) claim, including the internal appeal process and external review options.

Important Notice

Act Quickly:
- Appeal deadlines are strict (often 60-180 days from denial)
- Check your denial letter for specific deadline
- Continue paying premiums to keep policy in force during appeal

Many Denials Are Overturned:
Initial claim denials are common, but many are successfully appealed with proper documentation and persistence.

Part 1: Policy and Claim Information

Policyholder Information

Policy Information

Claim Information

Care Provider Information

Part 2: Denial Details

Denial Letter Review

☐ Denial letter received (Date: ___________)
☐ Denial letter attached to this appeal

Reason(s) for Denial (from denial letter)

☐ Does not meet benefit trigger requirements
☐ Does not meet Activities of Daily Living (ADL) criteria
☐ Cognitive impairment not substantiated
☐ Care is not from a qualified provider
☐ Elimination/waiting period not satisfied
☐ Pre-existing condition exclusion
☐ Policy lapsed for non-payment
☐ Care is not medically necessary
☐ Missing documentation
☐ Unauthorized provider/facility
☐ Service not covered under policy
☐ Other: _________________________________

Specific Language from Denial Letter

(Copy the exact reasons stated):

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Policy Provisions Cited in Denial

Part 3: Understanding Your Policy

Benefit Triggers

Most LTCI policies require meeting one of these benefit triggers:

ADL Trigger - Activities of Daily Living:
Policy requires inability to perform _____ ADLs (typically 2 of 6)

Cognitive Impairment Trigger:
☐ Substantial supervision required due to cognitive impairment
☐ Alzheimer's, dementia, or other cognitive condition diagnosed

Elimination Period (Waiting Period)

Covered Services Per Policy

☐ Nursing home/skilled nursing facility
☐ Assisted living facility
☐ Adult day care
☐ Home health care
☐ Hospice care
☐ Respite care
☐ Other: _________________________________

Policy Maximums

Part 4: Grounds for Appeal

Why the Denial is Wrong (check all that apply)

Eligibility Requirements Met:
☐ Claimant DOES meet ADL requirements (documentation attached)
☐ Claimant DOES have qualifying cognitive impairment (documentation attached)
☐ Elimination period HAS been satisfied (documentation attached)
☐ Pre-existing condition exclusion does NOT apply (documentation attached)
☐ Policy was in force at time of claim (documentation attached)

Care Provider/Service Issues:
☐ Provider IS qualified under policy terms
☐ Facility IS licensed as required
☐ Care IS medically necessary (physician statement attached)
☐ Service IS covered under policy terms

Documentation Issues:
☐ Required documentation IS now provided
☐ Insurance company failed to request additional documentation
☐ Documentation was already provided but not considered

Procedural Issues:
☐ Denial did not follow proper procedures
☐ Assessment was not conducted properly
☐ Relevant medical records not reviewed
☐ Company failed to obtain required information

Other:
☐ Other grounds: _________________________________

Part 5: Supporting Documentation Checklist

Medical Documentation

☐ Attending physician statement (completed by treating doctor)
☐ Medical records supporting need for care
☐ Cognitive assessment results (if cognitive impairment claimed)
☐ Functional assessment/ADL evaluation
☐ Plan of care from healthcare provider
☐ Hospital discharge summary (if applicable)
☐ Nursing notes documenting care needs
☐ Therapy notes (PT, OT, Speech)

ADL Documentation

☐ Detailed description of assistance needed for each ADL
☐ Care logs showing actual assistance provided
☐ Assessment from physician documenting ADL limitations
☐ Assessment from licensed healthcare professional

Provider Documentation

☐ Facility license
☐ Provider credentials/certifications
☐ Care provider agreement/contract
☐ Itemized bills for services provided

Policy Documentation

☐ Copy of insurance policy
☐ Certificate of coverage
☐ Any policy amendments or riders
☐ Premium payment records

Correspondence

☐ Original claim submission
☐ Denial letter
☐ All correspondence with insurance company
☐ Notes from phone calls (dates, names, what was said)

Part 6: Internal Appeal Process

Step 1: Review Denial and Deadline

☐ Reviewed denial letter thoroughly
☐ Identified specific reasons for denial
☐ Noted appeal deadline: _______________
☐ Identified what documentation is needed

Step 2: Gather Supporting Documents

☐ Obtained medical records
☐ Obtained physician statements
☐ Gathered care documentation
☐ Reviewed policy terms

Step 3: Write Appeal Letter

☐ Addressed each reason for denial
☐ Cited specific policy provisions
☐ Included supporting documentation
☐ Met formatting requirements

Step 4: Submit Appeal

☐ Appeal submitted before deadline
☐ Sent by certified mail, return receipt requested
☐ Kept copy of everything submitted
☐ Noted confirmation/tracking number

Appeal Submission Information

Part 7: Internal Appeal Letter Template

[YOUR NAME]
[YOUR ADDRESS]
[CITY, STATE ZIP]
[PHONE]
[EMAIL]

[DATE]

[INSURANCE COMPANY NAME]
Appeals Department
[ADDRESS]
[CITY, STATE ZIP]

RE: APPEAL OF CLAIM DENIAL
Policyholder: [NAME]
Policy Number: [POLICY NUMBER]
Claim Number: [CLAIM NUMBER]
Date of Denial: [DATE]

Dear Appeals Committee:

I am writing to formally appeal the denial of my long-term care insurance claim dated [denial date]. I believe this denial was made in error, and I am providing additional documentation to support my claim.

POLICY INFORMATION:
- Policy Number: [Number]
- Effective Date: [Date]
- Type of Care: [Nursing home/assisted living/home care]
- Care Start Date: [Date]
- Daily Benefit: $[Amount]

DENIAL REASON:
According to your letter dated [date], my claim was denied because:
[Quote exact language from denial letter]

WHY THE DENIAL IS INCORRECT:

[Address each reason for denial specifically. Examples:]

1. Regarding Activities of Daily Living (ADL) Requirements:

Your denial states that I do not meet the ADL trigger requirement of needing assistance with [number] ADLs. However, as documented in the attached physician statement and medical records, I require substantial assistance with the following ADLs:

• Bathing: [Describe specific limitations and assistance needed]
• Dressing: [Describe specific limitations and assistance needed]
• [Other ADLs]: [Describe]

The attached functional assessment from Dr. [Name] dated [date] confirms that I meet the policy's benefit trigger requirements.

2. Regarding [Second Denial Reason]:

[Address with specific facts and documentation]

3. Regarding [Third Denial Reason, if applicable]:

[Address with specific facts and documentation]

POLICY PROVISIONS:

Under my policy, benefits are payable when [cite specific policy language]. As demonstrated by the enclosed documentation, I meet these requirements because [explain].

ENCLOSED DOCUMENTATION:

I am enclosing the following documents in support of this appeal:
1. [List each document]
2. [Continue listing]
3. [Continue listing]

REQUEST:

Based on the above, I respectfully request that you:
1. Reverse the denial of my claim
2. Approve benefits effective [date]
3. Process payment for services rendered

Please acknowledge receipt of this appeal and provide a written decision within the timeframe required by [state] law.

If you require any additional information, please contact me immediately at [phone] or [email].

Thank you for your prompt attention to this matter.

Sincerely,

_________________________________
[Your Signature]

[Your Printed Name]

Enclosures: [List all attachments]

cc: [Your attorney, if applicable]
[State Insurance Department, if applicable]

Part 8: If Internal Appeal is Denied

External Review Options

If your internal appeal is denied, you may have additional options:

State Insurance Department Review:
☐ File complaint with state insurance commissioner
☐ Request external review (if available in your state)

Independent External Review:
☐ Some states require insurers to offer external review
☐ Review is conducted by independent third party
☐ Decision is usually binding on insurer

Legal Action:
☐ Consult with attorney about lawsuit
☐ Consider small claims court for smaller amounts
☐ Explore bad faith insurance claims

State Insurance Department

Filing a Complaint with State Insurance Department

What to Include:
☐ Copy of policy
☐ Copy of claim and denial
☐ Copy of appeal and response
☐ Description of issue
☐ Requested resolution

Part 9: Complaint Letter to State Insurance Department

[DATE]

[STATE] Department of Insurance
Consumer Complaints Division
[ADDRESS]
[CITY, STATE ZIP]

RE: Complaint Against [INSURANCE COMPANY]
Policyholder: [NAME]
Policy Number: [NUMBER]

Dear Insurance Commissioner:

I am filing a complaint against [Insurance Company] regarding their wrongful denial of my long-term care insurance claim.

POLICY INFORMATION:
- Insurance Company: [Name]
- Policy Number: [Number]
- Type of Policy: Long-Term Care Insurance
- Issue: Wrongful claim denial

SUMMARY OF COMPLAINT:

[Provide a clear summary of what happened, including:
- When you filed the claim
- The reason for denial
- Your appeal efforts
- Why you believe the denial is wrong]

CHRONOLOGY OF EVENTS:

[Date] - Began receiving long-term care at [facility/home]
[Date] - Filed claim with [Insurance Company]
[Date] - Received denial letter stating [reason]
[Date] - Filed internal appeal with supporting documentation
[Date] - Appeal denied because [reason]
[Present] - Filing this complaint

POLICY PROVISIONS:

My policy provides coverage for [describe coverage]. Under the terms of my policy, benefits are triggered when [describe trigger]. I meet these requirements because [explain].

REQUEST:

I request that the Department of Insurance:
1. Review my complaint
2. Investigate [Insurance Company]'s denial practices
3. Order [Insurance Company] to pay my claim
4. Take any other appropriate action

ENCLOSED DOCUMENTS:
1. Copy of insurance policy
2. Claim submission documents
3. Denial letter
4. Appeal letter and supporting documents
5. Appeal denial letter
6. [Other relevant documents]

Thank you for your assistance.

Sincerely,

_________________________________
[Your Signature]

[Your Name]
[Address]
[Phone]
[Email]

Part 10: Common Denial Reasons and Responses

"Does Not Meet ADL Requirements"

Response Strategy:
☐ Obtain detailed physician statement documenting each ADL limitation
☐ Get functional assessment from licensed healthcare professional
☐ Provide care logs showing actual assistance provided
☐ Include specific examples of what happens without assistance

"Cognitive Impairment Not Substantiated"

Response Strategy:
☐ Obtain neurological or psychiatric evaluation
☐ Provide cognitive testing results (MMSE, MoCA, etc.)
☐ Include diagnosis of dementia, Alzheimer's, or related condition
☐ Document need for substantial supervision

"Provider Not Qualified"

Response Strategy:
☐ Verify provider meets policy requirements
☐ Obtain provider's license and credentials
☐ Show provider is same type as specified in policy
☐ Request policy definition of "qualified provider"

"Elimination Period Not Satisfied"

Response Strategy:
☐ Document exact care start date
☐ Provide calendar showing days of care
☐ Clarify what counts toward elimination period in your policy
☐ Include invoices/records showing continuous care

"Pre-Existing Condition"

Response Strategy:
☐ Determine policy's pre-existing condition period
☐ Show condition was disclosed on application
☐ Demonstrate current need is unrelated to pre-existing condition
☐ Show pre-existing condition exclusion period has passed

"Care Not Medically Necessary"

Response Strategy:
☐ Obtain physician statement of medical necessity
☐ Include detailed care plan
☐ Document what would happen without care
☐ Show care is prescribed by physician

Part 11: Appeal Timeline Tracking

Key Dates

Communication Log

Part 12: Getting Help

Professional Assistance

Long-Term Care Insurance Specialists:
- American Association for Long-Term Care Insurance (AALTCI)
- Website: aaltci.org
- Claims assistance programs available

Elder Law Attorneys:
☐ Can review denial and policy
☐ Can handle appeals and litigation
☐ May work on contingency for wrongful denials

Insurance Bad Faith Attorneys:
☐ Specialize in insurance company misconduct
☐ May recover additional damages

State Resources:
☐ State Insurance Department consumer assistance
☐ State SHIP (State Health Insurance Assistance Program)
☐ Legal aid organizations

Questions to Ask an Attorney

☐ Do you handle long-term care insurance disputes?
☐ What is your experience with appeals?
☐ What are my chances of success?
☐ What are your fees?
☐ Do you work on contingency?
☐ What additional damages might be available?

Part 13: Protecting Your Rights

During the Appeal Process

☐ Continue paying premiums - Don't let policy lapse
☐ Keep all documents - Create copies of everything
☐ Document all communications - Note dates, names, content
☐ Meet all deadlines - Appeals have strict time limits
☐ Send by certified mail - Get proof of delivery
☐ Request everything in writing - Don't rely on verbal promises

Know Your Rights

☐ Right to appeal denial
☐ Right to receive denial in writing with reasons
☐ Right to review your claim file
☐ Right to external review (in many states)
☐ Right to file complaint with state insurance department
☐ Right to sue for benefits and potentially bad faith

Part 14: Resources

Insurance Company Contact

State Insurance Department

Professional Resources

Signatures

Appellant Certification:

I certify that the information in this appeal is true and accurate to the best of my knowledge.

Signature: _________________________________ Date: _______________

Print Name: _________________________________

This template is for informational purposes only and does not constitute legal advice. Consult with an attorney or insurance professional for specific guidance on your long-term care insurance claim.