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What You Need To Know About Getting Your Long Term Care Insurance Claim Paid

Dana Larsen
By Dana LarsenMay 17, 2013
Rising Cost of LTC Insurance

If you or a loved one has had trouble getting long term care insurance claims paid, know that you have options. Long term care can be both expensive and taxing on caregivers. Learn about some of the legal options available to you.

Rising Cost of LTC InsuranceMany families across the country are facing, or will soon be facing, paying for long term care for a loved one. As lawyers who work with insurance companies over denied long term care benefits, we understand how difficult this life stage can sometimes be.

The first step in getting your Long Term Care (LTC) Claim paid is recognizing that not all policies are the same. Oftentimes, older policies have more restrictive coverage – providing either “Nursing Home” benefits (which pay for room and board) orHome Health Care” benefits (which pay for a qualified Home Health Care Provider). Newer policies, however, tend to provide benefits for both types of care. You will need to take a close look at your policy to determine the type of benefits provided. You can (and if you don’t have it, should) request a copy of your policy from your insurance company or employer (for group policies).

What determines eligibility for LTC benefits?

While the language of older policies typically focuses on “medical necessity,” more current policies are centered around an inability to perform two or more activities of daily living (ADL) without “hands on” or “stand by” (within an arm’s length) assistance. For instance, if you cannot perform ADL’s like eating, bathing, and dressing without assistance, you will likely meet your policy’s criteria for LTC benefits. However, meeting criteria for your LTC benefits is not sufficient on its own. You must have a physician confirm your inability to perform these ADL’s, or the presence of a cognitive impairment, and then recommend care to an appropriate licensed or eligible care provider.

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Now that you understand the terms of your policy, and a physician has determined that you are in need of your LTC benefits, it is time to begin the claims process. Be sure that your physician established “Plan of Care” is consistent with the type of care that is covered under your policy.

What should I submit with my claim?

It is important that you do not let the claim forms limit you in conveying your restrictions. Include as much evidence as possible, and feel free to go beyond what the claim form allows. After carefully reviewing the claim forms, include certification by your physician stating that the treatment being requested is necessary. Once your claim has been submitted, we recommend that all of your communication with the insurance company be done in writing; however we understand that this is not always possible. If you must communicate with the insurance company orally, remember to obtain the name of the person to whom you are speaking and confirm the conversation with follow up correspondence. It is always a good idea to send correspondence by both regular mail, and certified mail that can be tracked.

What should I expect once my claim has been submitted?

After submitting your LTC claim, the insurer might conduct an assessment, either in person or telephonic, to verify your need for care. Be sure that you have a family member or knowledgeable caregiver present during this assessment to ensure that accurate information is being obtained! Note that policies issued after 2000 mandate that benefits cannot be denied without giving the insured an in person assessment by an independent licensed health care provider.

The facility that will provide your care also plays an important role in the claims process. The facility will need to provide forms proving that they qualify as an eligible provider under your policy, and include an assessment of you which determines your specific needs.

Insurance companies acting in good faith usually pay claims on a timely basis. However, many insurance companies are notorious for stalling the claim, in hopes that you will give up.  Because most LTC insureds are elderly, infirm, or cognitively impaired, they are vulnerable. We have seen insurance companies that do not hesitate to take advantage of these vulnerabilities. Be aware that many insurance companies will:

  • Interpret the language of your policy to their own best interest
  • Deny receiving necessary documents from you
  • Utilize biased doctors and nurses to justify a denial of your claim
  • Ignore, or fail to advise you about the benefits to which you are entitled

Although battling an insurance company can be a difficult and frustrating endeavor, it is a fight that must be fought for those in need of long term care. If you find that your insurer unfairly denies your claim for LTC benefits, it may be beneficial to seek out advice from a reputable and experienced attorney in this field of law.

About the Author: Kantor & Kantor is one of the most experienced and highly respected law firms dealing with the prosecution of claims against insurance companies. We represent clients whose insurance companies have failed or refused to pay claims arising out of Disability, Health, Life, Long Term Care and other liability insurance claims.

At Kantor & Kantor, we understand that an insurance denial is not the final word. If your long term care insurance claim has been unfairly denied, feel free to contact us at (800) 446-7529 or visit KantorLaw.net.

Have you or a loved one had trouble getting your long term care insurance claims paid? Feel free to share your stories and lessons learned in the comments section below.

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Dana Larsen
Dana Larsen

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