Long-term-care insurance policies (LTC) cover some of the costs of nursing and home health care, or assisted living facility needs if you or loved are unable to do Activities of Daily Living. While most people assume that Medicare and Medicaid will cover their nursing care needs, or home health care needs, or alternative living facility needs, these programs don’t always pay the full bill. And the government has strict spend-down requirements, which might require you to deplete your savings and assets.
For these reasons, many financial planners suggest LTC insurance as part of an estate or end-of-life plan. Below, Jonathan M. Feigenbaum, Esquire explains the four-step process of filing a claim for LTC benefits.
Step 1: Carefully Review the LTC Policy’s Terms
Long-term-care policies differ dramatically. If you discover that your loved one has LTC insurance, you should review the policy before you file a claim. While some policies cover any type of facility, including in-home care and assisted living, others will only pay for services at a nursing home.
You’ll also want to see if the LTC policy has a waiting or “elimination” period. During this time (which is can be up to 100 days), the patient must pay for all of his or her care out-of-pocket.
You can request a copy of the LTC policy from your agent or the insurance company. However, some of these policies use highly technical language and are difficult to interpret. If you need help understanding the terms and conditions of a long-term-care policy, contact an experienced insurance benefits attorney.
Step 2: Understand the Policy’s Benefit Trigger
Most, if not all, long term care plans have a “benefit trigger,” or a set of eligibility requirements. They typically involve your ability to care for yourself. When you file a claim, the insurance company will assess your (or your loved one’s) ability to independently engage in Activities of Daily Living:
- Perform personal hygiene activities (such as showering, bathing, and brushing teeth)
- Dress yourself
- Use the toilet
- Eat and prepare meals
- Ambulate — safely move around
- Cognitive impairment — make good decisions and think clearly and not endanger yourself
Sometimes if you cannot do 2 or 3 of the above Activities of Daily Living, you might qualify for long term care benefits. And you can always consult with treating physicians and a skilled insurance benefit lawyer if you need help assessing you or a loved one’s eligibility.
Step 3: File Your Claim and Participate in the Claim Investigation
Once you understand the policy’s requirements and assess your eligibility, you can file a claim with the long- term-care insurance company. This might involve the following:
- Completing a series of forms
- Participating in an initial phone assessment
- Meeting face-to-face with an insurance adjuster
- Submitting medical records from your doctors and the nursing facility
- Getting a statement from your treating physician
- Proposing a long-term care plan
- Providing other information that helps explain why you qualify
This process can seem overwhelming when you’re dealing with serious medical issues. While you should consider having a family member coordinate your application (and have a durable power of attorney), a skilled insurance benefit lawyer can assist in the process so that you properly complete the application process and present a compelling case why you should get paid the benefits you paid for and deserve.
Remember, long-term-care insurance companies are for-profit businesses. They look for reasons to deny claims and save money — especially if the claim involves intensive and prolonged medical treatment. Many LTC policies were priced too low and have resulted in losses to insurance companies.
Step 4: Receive Benefits or File an Appeal
Once the insurance company completes its investigation, it will either approve or deny your claim. If it approves your claim, it typically will reimburse you for long term care expenses. If it denies your application, you have the right to appeal. However, long-term-care insurance policies typically have strict appeal deadlines and processes. Before you initiate an appeal, you should always consult with a lawyer.
Schedule a No-Risk Consultation With an Experienced Attorney Knowledgeable in Long-Term-Care Products
Jonathan M. Feigenbaum, Esquire assists families nationwide with long-term-care insurance applications and appeals and litigation. He is a respected disability insurance advocate with extensive experience handling claims for long-term-care insurance, disability payments, health benefits, and life insurance. You can schedule a free, no-risk consultation by calling his office or completing a simple, online form.