What to do when National Insurance has refused a claim for the long-term care benefit or set too low a level: what to check in the decision, how to obtain the assessment report, how to appeal in time and what improves your chances.
First of all — the deadline
Before any substantive examination, find the deadline for lodging an appeal in the letter. It is the one detail that cannot be put right after the event.
National Insurance deadlines are not flexible, and missing one may close off the possibility of acting — even where the argument is entirely justified.
If you are close to the deadline and still gathering material, you can consider lodging an appeal in time on the grounds you already have, stating that further material will follow. It is better to be inside the process than outside it.
Identify exactly what was decided
There is a substantive difference between a full refusal and a level that is too low, and dealing with each is different.
A full refusal may stem from failing a threshold condition — age, residence, an income test — or from a finding that sufficient dependency was not found. In the first case it is a technical question about which there is usually no factual dispute; in the second it is a functional dispute.
Too low a level is almost always a dispute about the assessment. Here the central tool is the dependency assessment report.
Obtain the assessment report
This is the most important practical step. The decision letter usually gives the outcome alone; the report sets out what was found in each functional area.
Without the report you do not know whether the person was found independent in bathing, in dressing or in transfers — and so you cannot build a focused argument.
When the report arrives, go through it area by area and mark every place where what is recorded does not match reality. Those are the points the appeal will concentrate on.
What improves your chances
An appeal that describes how difficult the situation is, without addressing a specific area and without supporting material, is refused in most cases. A focused and supported appeal is taken seriously.
- Addressing a specific area recorded as independent, explaining what actually happens
- An up-to-date medical document addressing that same area
- A functional diary with dates and frequencies
- An occupational therapy or physiotherapy report
- Documentation of falls, admissions or safety incidents
- A carer's contract and payslips, if there are any
- An explicit note if the situation on the day of the assessment was better than usual
When the condition has deteriorated since the decision
It is important to distinguish between an appeal and a request based on deterioration. An appeal argues that the decision was wrong at the time. A request based on deterioration argues that the situation has changed since the decision.
If there has genuinely been a documented deterioration — rather than the assessment simply having been inaccurate — the right route may be a request for reassessment rather than an appeal.
Sometimes both routes are relevant. In that case it is worth clarifying with National Insurance which is the right one in the specific situation.
And in parallel — the private policy
A refusal or a low level at National Insurance is not a conclusion about a long-term care insurance policy. These are separate routes assessed under different rules.
More than that: if the refusal at National Insurance stemmed from threshold conditions that are not functional — an income test, for example — it says nothing about the functional condition, and the definition in the policy may be fully satisfied.
So this is a good moment to check whether there is a long-term care policy that has not been examined.
Frequently asked questions
How long do you have to appeal a National Insurance decision on long-term care?
The deadline is stated in the decision letter and it is not flexible. If the deadline is close and you are still gathering material, you can consider lodging in time on the grounds you have and stating that further material will follow.
What is the first step after a refusal?
Obtain the dependency assessment report. The decision letter gives the outcome alone, whereas the report sets out what was found in each functional area — and that is the starting point for any argument.
What is the difference between an appeal and a request based on deterioration?
An appeal argues that the decision was wrong at the time. A request based on deterioration argues that a real, documented change has occurred since the decision. Sometimes both routes are relevant and you should establish which is right in the specific situation.
What improves the chances of an appeal succeeding?
Addressing a specific area recorded as independent, accompanied by supporting material — an up-to-date medical document, a functional diary with frequencies, an occupational therapy report, and documentation of falls or admissions.
We were refused by National Insurance — is there any point checking a private policy?
Absolutely. These are separate routes. If the refusal stemmed from threshold conditions that are not functional, such as an income test, it says nothing about the functional condition and the definition in the policy may be satisfied.
Official sources for further checking
This is general information and does not replace personal medical, legal or insurance advice. Eligibility is determined by the documents and rules that apply to each case.
