Getting Long-Term Care Benefits Paid

Years ago, you or a loved one invested wisely in a long-term care insurance policy. Now, as your family prepares to make an LTC claim, you may scratch your head about the terms, conditions, and claims procedures within your loved one’s insurance policy.

You don’t have to navigate your claim alone. Jonathan M. Feigenbaum, Esquire has assisted policyholders with countless LTC claims and know what it takes to get your long-term care benefits paid.

Get Authorization to Act in Policy Disputes

If a friend or loved one needs long-term care, get a signed statement authorizing you to act on his or her behalf in policy disputes. It need not be a power of attorney — just a statement that’s signed. A durable power of attorney is preferred. Remember to do this early, particularly if there is history of memory loss in the insured’s family medical history.

You may also want to consider changing your loved one’s mailing address to your residence or office. That way, you will get copies of any correspondence from the long-term care insurer — and you can respond. If you retain a long-term care attorney, the insurance company is obligated to send queries and notices, to your attorney who can respond for the policyholder.

Read the Policy

If you don’t have the policy or can’t find it, ask the insurance company to send a duplicate. Never submit a claim without first reading the insurance policy first.  You need to know what the insurance company requires so you qualify for benefits. This is why reading the policy is so important before submitting a claim.

Submit as Much Evidence as Possible

When filing a claim, don’t feel confined to the minimal space on the claim form. You can insert in the form, “See the attached exhibit A.” Then, using your favorite word processing software, write-up as much information as you need to support the claim.  Don’t feel constrained by the boxes on the form as well.  Submit as much as evidence as you must substantiate your claim, such as information from your parent’s physician or caregiver. Include a physician’s ‘certification of necessity of treatment’ or ‘plan of care.’ Add photographs, for example, showing the assistive devices the insured uses, such as a cane, walker, showering assistive devices and others that tell a story.

Put It in Writing

If you’re having trouble getting the insurer to pay a claim, put it in writing and send the letter to the company. Don’t try to resolve a problem over the phone. Create a paper trail to track what was said and by whom. A letter doesn’t leave room for ambiguity the way a phone call does. Just because the insurance company tells you it records all calls, don’t rely on the insurer to make those recordings available.

If the insurer makes an unreasonable demand, such as demanding a power of attorney to represent your parent, send a letter stating,  “You instructed us that we need power of attorney. Please provide the authority for that demand, because I cannot find it in the insurance policy.”

You should build a file that contains all of your notes and correspondence with the insurance company. Save copies of your letters. Often corresponding by fax is a good way to maintain your paper trail. Many insurance companies will not correspond by email. Fax is instant, you can get a receipt, and it’s cheaper than sending certified mail, return receipt requested.

Get Daily Care Notes

If you plan to hire a home health aide from an agency, make sure the aide will keep “daily care notes.” Insurers often demand these before approving home-care claims. This is extremely important. Without daily care notes, the likelihood of receiving payment is slim.

Don’t Let Your Friend or Loved One Face the Insurance Company Alone

Be with your friend or loved ones when the insurer sends an employee or agent to conduct an assessment. The policyholder might be too proud to tell the interviewer what he cannot do — such as dressing, feeding or bathing himself — which could lead to a claim denial. If you’re present, you can set the record straight and encourage the policyholder to demonstrate his limitations. A supportive voice will help your friend or loved one get paid.

Set Up Third Party Designee

Inform the insurer you want to be a third party designee and receive a copy of any lapse notices. This way, if there is an issue with premium payments, you’ll know and you can make sure the premium gets paid.

Understanding How LTC Claim Policies Work

While every LTC policy is different, some common elements are important to understand. First, you do not become eligible for benefits until the beneficiary’s health condition meets certain standards. Typically, you must show that they are unable to perform two essential activities of daily living (ADLs) or suffer from significant cognitive impairments.

Evaluating Your Loved One’s ADLs

The long-term care policy may contain a specific list of covered activities of daily living (ADLs) that it considers. Most LTC policies contain four to six overarching activities of daily living that the adjuster will assess during the claims process.

Many families do not realize that long-term care insurance companies strictly apply their ADL criteria, and they need to carefully document their loved one’s limitations and consider the exact criteria within the LTC plan.

It’s easy to assume that many hallmarks of independent living are ADLs. However, just because your loved one can no longer drive, make complex meals, or consistently take their medications, does not mean they lack essential ADLs. Instead, most LTC policies include activities like:

  • Bathing
  • Using the toilet
  • Getting in and out of bed
  • Dressing oneself
  • Feeding oneself

For example, there is more to feeding than just eating. Think about the physical steps from holding a fork, to picking it up, spearing a tomato in a salad, bringing it to your mouth, biting the tomato and putting the fork down and repeating the process. A person with a movement disorder, might have extreme trouble completing this process that a healthy person takes for granted.

Evaluating Your Loved One’s Cognitive Impairment

You may have a library of anecdotal information about your loved one’s cognitive decline. However, your (admittedly terrifying) stories of your parent getting lost on the way to the grocery store, forgetting their grandchild, or leaving the stove on, won’t be sufficient to get their long-term care benefits paid.

A cognitive impairment-based LTC claim requires a medical diagnosis and precise documentation of your loved one’s limitations. For example, your family member may have to take cognitive assessments or tests that gauge their ability to think, process information, and decide. Some of the testing is simple, such as the Montreal Cognitive Assessment (MoCA), a brief 30-question test that takes around 10 to 12 minutes to complete and helps assess memory impairment. There are thousands of neuropsychological instruments available to clinicians, but sometimes the MoCa test can be sufficient.

What Does a Long-Term Care Policy Cover?

While more and more of us want to “age in place,” that doesn’t mean your LTC insurance will cover it. Again, you need to carefully review the language of the long-term care policy before you make a claim for benefits. Some LTC plans will pay for both traditional facility-based care and in-home options that many people prefer.

However, many long-term care plans strictly define a “nursing home.” Your loved one’s assisted living community may not meet these criteria, especially if it offers very limited support or allows for very independent living. If you’re unsure whether your loved one’s needs and preferred facility qualify under their LTC policy, contact our office. We can help you understand the exact criteria that your claim will involve — and help you build strategies for getting long-term care benefits paid.

Ready to Talk? Call Today for a Complimentary Assessment of Your Long-Term Care Claim

Jonathan M. Feigenbaum, Esquire guides families through the LTC claims process, and litigation when necessary. Whether you’re about to file a claim or are facing obstacles in an existing claim, an LTC attorney can help you understand your legal options.