Questions & answers · Long-term care insurance
My long-term care insurance denied my claim for this — why, and is that allowed?
Long-term care insuranceDeniedTexasChecked Nov 6, 2026
From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-06 · Source: Texas Insurance Code · § 541.060 «Unfair Settlement Practices» · (a)(3) View original ↗
In short
- The insurer must give you a real, written reason for the denial.
- Then read the benefit trigger in your own policy and compare it.
- A denial about your form has a limit — it must be a big fact.
What this means
Start with a written explanation. Texas law says the insurer must promptly tell you, in writing, the policy-based reason it denied your claim [1].
One common reason is the "benefit trigger." Your policy sets a test, such as needing help with daily tasks, that must be met first. The test itself lives in your policy, not in a statute we can quote here. State rules only set minimum standards for that test [3].
Another common reason is something on your application. For most of these policies, that defense only works if the fact was important and it changed the risk the insurer took on [2]. Ask which fact the insurer means.
Your next step
Ask for the written reason now. Put it in a letter or an email you keep. These sources set no deadline for that answer.
Check it yourself
Put the insurer's reason next to your policy's own words. Read the "benefit trigger." Read how the policy defines a "chronically ill" person. Then see if the reason matches.
Where this comes from (3)
[1] Texas Insurance Code · § 541.060 «Unfair Settlement Practices» · (a)(3) · checked 2026-11-06
failing to promptly provide to a policyholder a reasonable explanation of the basis in the policy, in relation to the facts or applicable law, for the insurer's denial of a claim or offer of a compromise settlement of a claim;
[2] Texas Insurance Code · § 705.051 «Immaterial Misrepresentation in Life, Accident, or Health Insurance Application» · (1)-(2) · checked 2026-11-06
A misrepresentation in an application for a life, accident, or health insurance policy does not defeat recovery under the policy unless the misrepresentation: (1) is of a material fact; and (2) affects the risks assumed.
[3] Texas Insurance Code · § 1201.105 «Minimum Standards for Benefits for Long-Term Care» · (a) · checked 2026-11-06
The commissioner shall adopt rules establishing minimum standards for benefits for long-term care coverage under individual, group, and blanket accident and health insurance policies and certificates delivered or issued for delivery in this state.
How we found this
We matched your question to 3 official sources, quoted the exact lines, and re-checked each quote against its source on 2026-11-06.
What we don’t know yet
Your own plan or notice may say something different. If your letter cites another rule, send it and we will look again.
Every answer is checked against the official rule it quotes.
Information only — not legal advice. Your plan, insurer or agency decides.
This answer quotes the official sources listed above, with the date we checked them. Your own policy, notice and state rules control. We are not your lawyer or your insurer. We don’t file, argue or negotiate claims for you — you send any letter or form yourself.
Answer id CQ2048. Spotted an error? Tell us.