Resource Aid Center

7 min read · Last updated August 10, 2026

In this article

• The moment it happens
• The first 24 hours: read the denial for the actual reason
• Why the count doesn’t match what you’re seeing at home
• The mistake that costs families their claim
• What to do at 30, 60, and 90 days
• FAQ

The moment it happens

The letter arrives on a Wednesday. Your mother’s long-term care claim, the one you filed after the home health assessment, comes back denied. The assessor’s notes say she needs assistance with two activities of daily living. The policy, according to the denial letter, requires three. Nothing about her actual day changed between the assessment and the letter. The number did.

The first 24 hours: read the denial for the actual reason

Before calling the insurer, read the denial letter twice for one thing: which ADL(s) the assessor found your parent could still perform independently, and what standard they applied to reach that conclusion. Most denial letters name the specific ADL and the specific finding. If yours doesn’t, that’s your first call: ask the claims department to send the assessor’s actual scoring notes, not just the summary letter.

Federal tax law defines the ADL trigger for tax-qualified policies, which cover most individually purchased LTC insurance sold today. 26 U.S.C. § 7702B(c)(2) requires the insured be “unable to perform (without substantial assistance from another individual) at least 2 activities of daily living for a period of at least 90 days.” It names eating, toileting, transferring, bathing, dressing, and continence as the six.

Separately, most states have adopted a model regulation written by the National Association of Insurance Commissioners (NAIC), the association of state insurance regulators that writes the template laws most states then enact. The NAIC Long-Term Care Insurance Model Regulation sets a ceiling: insurers can’t require more than 3 of those 6 ADLs. So “2 of 6” is the federal tax-qualified floor, and “3 of 6” is the outer limit non-tax-qualified policies can set. Find out which one your parent’s policy actually uses, because that single number is the whole dispute.

Why the count doesn’t match what you’re seeing at home

This is the part that catches families off guard, and it’s not because the assessor is wrong or the insurer is acting in bad faith. It’s a definitional gap built into the policy language itself.

The same NAIC model regulation spells out the standard for scoring a physical ADL. A deficiency can’t be counted unless it requires “the hands-on assistance of another person to perform the prescribed activities of daily living.” Verbal cueing or supervision only counts toward the trigger “if the deficiency is due to the presence of a cognitive impairment.” In plain terms: if your mother can button her own cardigan as long as someone stands there reminding her step by step, that’s supervision. Supervision only satisfies the ADL test through the cognitive-impairment path, not the physical-ADL path. A family logging “needs help dressing” every day is describing something real. An assessor scoring “dressing” as a physical ADL is asking a narrower question: does she need hands laid on her to get the sleeve on? Those are two different questions, and the letter often doesn’t say which one was asked.

There’s a second, independent way into the same benefit that doesn’t touch the ADL count at all. If your parent has severe cognitive impairment requiring supervision to protect them from health and safety risks, that alone qualifies them, regardless of how many physical ADLs they can still perform. If the denial only discusses the physical ADL count and your parent has a diagnosed cognitive condition, ask specifically why the cognitive-impairment trigger wasn’t evaluated.

The mistake that costs families their claim

The single most common mistake is appealing with more of the same evidence that got denied the first time. A general letter describing how much your parent struggles doesn’t help; the appeal needs evidence mapped to the exact ADL and exact standard the denial cited. If the denial says your mother doesn’t need hands-on assistance dressing, the appeal needs a caregiver’s written, dated log describing specific instances of physically assisting with a sleeve, a button, a zipper. Not a general statement that she “needs help getting dressed.” Match the evidence to the legal standard, not to how the day feels.

Get the physician involved early. A letter from your parent’s doctor documenting the specific level of assistance required for each contested ADL carries more weight in an appeal than a family description alone. The same is true of a letter documenting a cognitive-impairment diagnosis, if one exists.

What to do at 30, 60, and 90 days

By day 30 (or per your policy’s stated window): file the first-level internal appeal in writing, addressing the exact ADL and standard the denial cited. Under the model regulation most states use, you typically have 120 days from the denial to file this, but don’t wait; the insurer generally has 30 days to respond once your appeal is complete.

By day 60: if the first appeal is denied, file the second-level internal appeal within the same 120-day-style window, this time with the physician’s letter and any updated caregiver documentation attached.

By day 90: if internal appeals are exhausted, request independent external review. This step exists specifically so someone outside the insurer evaluates the same file, and under the NAIC model it must be completed within 30 days of the request. Oregon’s Division of Financial Regulation describes the mechanism directly: “If the denial is upheld by the company, your insurer must send you a letter telling you how to file an external appeal.” Exact day counts vary by state and policy, so confirm the numbers on your own denial letter and check your state’s Department of Insurance page rather than assuming the model timeline applies exactly as written.

If the crisis that led to this claim was your parent no longer being able to live alone, our guide to the first 72 hours after that realization covers what usually comes first. Those are the immediate safety and care decisions that come before the insurance paperwork even starts.

If a long-term care denial like this one means the family may need to lean on Medicaid instead, check whether any gift or property transfer made in the last five years could trigger a penalty period first. Medicaid’s five-year look-back and transfer-penalty math explains how that clock actually works, and it does not start where most families assume.

Frequently asked questions

How many activities of daily living does a policy usually require before it pays out? Most individually purchased, tax-qualified policies use the federal standard of needing substantial assistance with at least 2 of 6 ADLs for 90 days or more, or having severe cognitive impairment. Some policies, not bound by the tax-qualified standard, can require up to 3. Check your parent’s actual policy language, since this single number decides most disputes.

What are the six ADLs, exactly? Bathing, dressing, transferring (moving in or out of a bed or chair), toileting, continence, and eating. A policy denial almost always names one or two specific ADLs where the assessor’s finding differs from what the family observes at home.

If my parent just needs reminders, not physical help, does that count? It depends which trigger applies. Verbal reminders and supervision generally count toward the severe cognitive impairment path, not the physical ADL path. If your parent needs reminders because of a diagnosed cognitive condition, ask the insurer to evaluate the cognitive trigger specifically, separate from the ADL count.

How long do I have to appeal a long-term care claim denial? It varies by state and policy, but many states following the NAIC model give 120 days to file each internal appeal, with the insurer generally required to respond within 30 days. After internal appeals, you can typically request an independent external review, which must usually be completed within 30 days of the request. Confirm your exact deadlines on the denial letter itself.

Does a doctor’s letter actually change the outcome of an appeal? It often does, because a physician’s documentation of the specific level of assistance needed, tied to the exact ADL or cognitive standard in dispute, carries more evidentiary weight than a family’s general description. Ask the doctor to be specific about the type of assistance required, not just that assistance is needed.