Rights8/8/2026

Long-Term Care Insurance: When Are Benefits Payable and How Can a Claim Denial Be Appealed?

Eligibility for long-term care insurance benefits is generally linked to the loss of the ability to perform activities of daily living or to cognitive impairment requiring constant supervision. Denial of a claim by the insurer does not necessarily mark the end of the process: the conclusions of the insurer’s physician and the other grounds for denial may be reviewed in light of the policy terms, medical records, and limitation periods.

Key facts

•Source publication date: 22.07.2026
•ADL criterion: at least 3 of 6 activities
•Older policies: a limitation period of 3 years
•Policies from November 2022: a limitation period of 5 years
•The Insurance Contract Law is mentioned
•No case number or court name

Who May Be Eligible for Benefits

Policies generally establish two conditions for recognizing an insured event. The first is the inability to independently perform at least three of six ADL activities: getting up and lying down, moving around, eating and drinking, bathing, dressing, and controlling bodily functions. The second is a cognitive condition, such as Alzheimer’s disease, dementia, or another impairment requiring constant supervision. The precise conditions must be examined according to the wording of the rules in effect when the insured event occurred.

Why Insurers Deny Claims

The insurance company may argue that the insured is capable of performing activities of daily living, at least partially, and therefore does not meet the definition of a person requiring long-term care. To assess the person’s condition, the insurer may refer the person to a physician acting on its behalf and, in some cases, use materials obtained through covert surveillance. According to the source material, the insurer’s physician’s opinion is not final: it is possible to request a copy, demand a repeat examination, and submit an independent medical opinion.

Benefits for a Past Period

In appropriate circumstances, a claim may also be filed for a period that has already passed, during which the person was in a condition covered by the policy but did not receive benefits. To do so, the date on which this condition began and the applicable limitation period must be determined. The source states that under older policies this period is three years, while for policies purchased from November 2022 onward it is five years, pursuant to an amendment to the Insurance Contract Law.

What Is Important When Filing a Claim

Medical records and a description of limitations in daily life affect the assessment of the insured event. Incomplete records or imprecise wording may make it more difficult to examine the claim, even when the medical condition is severe. The source does not discuss a specific legal proceeding or cite a judgment, and therefore no outcome of any dispute between the insured and the company is stated.

What this means for you

A person whose claim has been denied should examine not only the insurer’s letter but also the policy’s precise terms, the date on which the condition arose, the medical material, and the limitation period. The denial itself or the opinion of the insurance company’s physician does not necessarily preclude reconsideration of the claim or the filing of a claim for benefits for a past period.

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