How to File a Claim
Generally, with most Long Term Care Insurance Policies, benefits are triggered when the person cannot perform at least two out of the six activities of daily living or ADLs or have received a diagnosis with a severe cognitive impairment such as dementia or Alzheimers.
The ADLs include bathing, dressing, toileting, eating, transferring, or incontinence.
To start a Long Term Care Insurance Claim the patient, a family member, or ideally an expert advisor will often call the carrier to start the process. The insurance provider will conduct an intake interview and then request forms from the client, the doctors, and the long-term care providers.
The insurance provider may ask for more records, they may ask a medical professional to conduct an in-person assessment. Then after all records and assessments are provided, then it can take another 45 days.
Be prepared for the entire process to take 60 to 90 days or more.
The person handling the claim must be very detailed oriented, the should document every phone call and make note of the date, the time, the name of the person spoken with, and a summary of the call. Keep copies of all records and follow up.
Five Common Claim Mistakes
Failing to Return Forms Promptly
Often, the doctors or care communities fail to submit their requested paperwork by the deadline. It is important to follow up with them and make sure they fill them out and submit them in a timely manner.
Choosing a Community that Does Not Meet Policy Standards
Most Long Term Care Insurance policies require that the care community have a Registered Nurse on duty at all times. Before you choose a community, ask your insurance carrier to provide a review of the community you are considering to avoid delays once the person moves in.
Community Does Not Have a State License
Most Long Term Care Insurance only cover home care agencies that are state-licensed. Before move-in, confirm the provider is licensed and approved by the insurance carrier.
Cognitively Impaired Person Fails Assessment
From time to time a cognitively impaired person is having a good, very lucid day. When the insurance carrier's representative visits to make an assessment, they don't seem to be impaired. Should a claim be denied, for this reason, file an appeal and ask for another assessment.
Not Planning for 90-Day Elimination Period
Some Long Term Care Policies have a 90-day elimination period that starts when care is received. They then have 90 days to wait until the elimination period is over, this is time that they may need assistance covered in some other way.
Leaving Money on the Table
When it comes to filing claims, families often leave thousands of dollars on the table by not realizing that they may be eligible for:
- Satisfying the elimination period → Average Value: $10,000-$20,000
- Reimbursement for previous care → Average Value: $1,000-$30,000
- Refund of paid premiums → Average Value: $1,000-$3,000
Getting Help with Claims
This claims process is complex. Not all clients nor their families are up to the task. There are third-party resources.
Sometimes the agent who sold the policy will help and other times the aid of an outside expert can ensure things are done correctly and save the family considerable burden.
But with getting help there are a few other items to keep in mind.
HIPAA Release Form
– Because of the Health Insurance Portability and Accountability Act of 1996, otherwise known as HIPPA to protect sensitive patient health information from being disclosed without the patient's consent or knowledge, there are release forms that must be signed by the patient. Ideally, the patient will complete these forms prior to needing to file a claim so the family or advisor can get records sent where they need to go in a timely manner.
Third-Party Claim Administrators
Most 3rd party administrators charge fees to process a claim. Before hiring a 3rd party claims administrator, do your research. Ask for advice from trusted advisors.
Getting Assistance with Long Term Care Insurance
Family Solutions for Care are long-term care insurance claims specialists. They help families collect Long Term Care insurance benefits.
