What Disqualifies You From Long Term Care Insurance

A woman in Suffolk called me after her husband was turned down for long term care insurance. He was 66, he had a mild tremor that his doctor was watching, and the application had asked about it. She wanted to know what else they could have done. The honest answer was that they should have applied five years earlier, and that the denial did not change what we needed to do next.

What disqualifies you is anything that tells the insurer you are likely to claim soon: a current need for help with daily activities, a diagnosis of dementia or mild cognitive impairment, certain chronic or progressive conditions, a recent hospital stay or rehab, advanced age, and some mental health history. Each insurer draws its own lines, so a decline from one is not always a decline from all. I am not an agent; a licensed agent can tell you where your situation lands.

The short answer: insurers decline people who are likely to claim

Long term care insurance is medically underwritten. Unlike Medicare, which covers everyone of a certain age, a private insurer chooses whom to accept, and it accepts people who are healthy enough that a claim is years away. The things that disqualify you are the things that predict a claim: needing help now, having a condition that will lead to needing help, or being old enough that the odds are too high.

That sounds harsh, and it is the reason I tell families with healthy parents in their fifties to at least have the conversation with an agent. The window for this product closes quietly, often with a diagnosis that seemed minor at the time. My post on whether long term care insurance is worth it covers the decision; this one covers whether you can get it at all.

What insurers want to see

In general terms, insurers look for an applicant within their age range, usually from the forties into the seventies, who can perform all the activities of daily living without help, has no cognitive impairment, has no condition expected to progress to a need for care, has not been hospitalized or in rehab recently, and is not using equipment like a wheelchair, walker or oxygen. Height and weight within the insurer’s range and no recent tobacco use help with the rate.

Each insurer gives its agents an underwriting guide with conditions sorted into accept, accept at a higher rate, postpone and decline. A good agent will prescreen you against several of them before anything is submitted, because a formal decline becomes part of your record and later applications will ask about it.

What disqualifies you

Here are the categories that most often lead to a decline, with examples drawn from how underwriting generally works. Your own case depends on the insurer, the details and the date.

Category	Examples	Why insurers decline
Age	Applying past the insurer’s maximum issue age, often somewhere in the seventies or eighties	The odds of a claim within a few years are too high to price
Cognitive impairment	Any diagnosis of dementia, Alzheimer’s or mild cognitive impairment; a failed cognitive screen during the application	Memory loss is the single most common reason for a long claim
Progressive neurological conditions	Parkinson’s disease, multiple sclerosis, ALS, Huntington’s disease, some stroke history	Expected to lead to a need for daily help
Current functional limits	Needing help with bathing, dressing, moving around or eating; using a wheelchair, walker or oxygen	The benefit trigger is already met or close to it
Serious chronic illness	Kidney failure on dialysis, advanced heart or lung disease, poorly controlled diabetes with complications, some cancers within a set number of years	High likelihood of decline or hospitalization
Recent hospital stay or rehab	A hospitalization, surgery with a long recovery, or a rehab stay within the past year or so	Insurers postpone until the person has been stable for a period
Mental health history	Recent psychiatric hospitalization, some diagnoses such as schizophrenia or bipolar disorder, untreated substance use	Tied in underwriting data to higher claim rates
Already receiving care	Living in assisted living, memory care or a nursing home, or receiving aides at home	The claim has, in effect, already started

Some of these are permanent. Others, like a recent surgery, are a postponement, and the agent can tell you how long to wait and reapply.

What raises the price but does not disqualify you

Plenty of conditions get you a policy at a higher rate rather than a decline. Controlled high blood pressure, well managed diabetes without complications, arthritis that does not limit daily activities, mild depression or anxiety that is treated and stable, a weight that sits a bit outside the preferred range, and tobacco use often fall into this group. Family history of dementia may affect the rate with some insurers and not others.

This is where applying through an agent who works with several carriers pays off. The same person can be a decline at one company and a standard rate at another, because each insurer weighs conditions differently and some specialize in certain risks.

The application and underwriting process

Knowing the steps helps families prepare and avoid an avoidable decline.

1. The application asks detailed health questions, lists medications and names every doctor seen in recent years.
2. The insurer orders medical records from those doctors, and for many applicants a prescription history.
3. A phone interview covers the same ground and, for applicants above a certain age, includes a cognitive screen such as recalling a list of words after a delay.
4. Some insurers send a nurse for a brief in person exam that checks blood pressure, height, weight, mobility and sometimes blood and urine.
5. Underwriting sorts the file into accept, accept at a higher rate, postpone or decline.
6. The decision arrives in writing, with the reason, which matters if you plan to apply elsewhere.

Be accurate. An insurer that finds an undisclosed condition in the records can decline the application, and if a policy was issued, it can contest a claim years later. Honest and complete beats hopeful every time.

How to avoid being disqualified

Most of what you can do happens before the application.

Apply earlier than feels necessary

The best age is the mid fifties to early sixties, while most people are still healthy enough to be accepted and the premium is still reasonable. Every year of delay raises both the price and the chance of a disqualifying diagnosis.

Get conditions controlled and documented

Blood pressure, diabetes, weight and depression that are treated and stable look very different to an underwriter than the same conditions untreated. Keep the follow up appointments; a chart that shows consistent care helps.

Prescreen with an experienced agent

Describe everything, including the tremor the doctor is watching, so the agent can pick the carrier most likely to accept and avoid a decline on your record.

Consider couples and hybrid products

Some insurers offer a couples discount and more flexible underwriting when both spouses apply. Hybrid life insurance policies with a long term care rider often use lighter underwriting than traditional policies, and some group plans through an employer ask fewer questions during an enrollment window. A licensed agent can explain the trade offs.

Prepare for the cognitive screen

Rest, take the call in a quiet room, and do not try to coach your way through it; the screen is designed to catch real impairment, and a borderline result can be retested.

How to pay for care without insurance

Most families I work with do not have a policy, and they get their parents into good communities. The money comes from a few places, and I explain the structure of each on the first call without quoting figures that change monthly; ask me for current numbers.

• Savings and retirement accounts, drawn on a schedule that matches the care plan.
• The house, through a sale, a rental or a loan against it, with an elder law attorney and a financial advisor involved.
• An existing life insurance policy, which can sometimes be converted or accelerated to pay for care, as I describe in using life insurance to cover senior living costs.
• Veterans benefits for a wartime veteran or surviving spouse who needs daily help; see my post on VA Aid and Attendance.
• Medicaid, for those who qualify, through a limited assisted living program with few participating communities on Long Island; details in does Medicaid pay for assisted living.

Medicare does not pay for assisted living, memory care or independent living rent. Families who assume it will lose months. My guide to how much assisted living costs explains how fees are built so you can see where each source fits.

What I tell families who were turned down

A decline changes the plan, not the outcome. The husband in Suffolk I mentioned at the start moved into a very good assisted living community two years later, paid for from savings and the house, with a plan that stretched far enough to cover memory care if the tremor became something more. His wife met with an elder law attorney early, which protected her own future in the house. That is the shape of most of my cases.

What a decline does mean is that the planning horizon matters more. I plan 18 to 24 months past the move so a rising level of care is anticipated, and without a policy that horizon is what keeps the family from a second move or an unplanned spend down. I have toured more than 90 communities across Nassau, Suffolk and Queens, I know which ones have memory care under the same roof, and I know how each one structures its fees. Bring the decline letter to our first call; it tells me something about health that helps me choose.

Insurance or not, the help is free

Assisted Living Locators of Long Island helps families across Nassau, Suffolk and Queens choose assisted living, memory care or independent living with a realistic plan for paying for it, and the help is free to families; communities compensate the advisor when a family moves in. I am not an insurance agent, an attorney or a financial advisor, and I will tell you when to call one.

My office is at 42 Prospect Ave, Glen Cove, NY 11542. Set up that first call.

Questions readers ask

Read next

• Is Long Term Care Insurance Worth It for Long Island Families?
• How Long Term Care Insurance Works When You Move Into Assisted Living
• Does Medicare Cover Long Term Care? The Short Answer and the Exceptions