What to expect when filing your first long term care claim

Filing one’s first long term care insurance claim is daunting for anyone. There is worry that the company will deny one’s claim. There is also simultaneously stress that one’s loved one is now needing a higher level of care for which you need the long term policy to help pay for. While each company has its own process for qualifying for benefits, in general they all require the same set of documents.

However, before diving into what documents to gather, first take some time to review the policy itself, paying special attention to these factors:

1. What are the requirements to exercise the plan?
   Typically, mom must need help with at least two Activities of Daily Living (ADLs), which include bathing, eating, dressing, toileting and transferring OR must be cognitively impaired to the extent that she can no longer safely care for herself alone. Does Mom meet these conditions now?
2. What does the plan cover?
   Home care by an agency or individuals? Adult day program? Residential care? Medical equipment? Respite care? etc.
3. What requirements must the service provider meet?
   For example, if home care, must the provider be a Certified Nurse Assistant? Must services be provided a licensed agency?
4. Is there an “elimination period?”
   In other words, must you private pay for 60, 90 or 120 days before the company will begin reimbursing you for expenses which qualify? If this is the case, perhaps it makes sense to use less expensive home care to use up your elimination days before going into more expensive residential care?
5. What is the maximum amount of benefit per day?
6. What is the maximum amount of benefit over the policy’s lifetime?
7. Who has permission to call on behalf of the policy owner? What is the process for adding adult children to this list?
   If not, you will need to call with your parent and your parent will have to ask what forms to submit to enable you, the adult child, to speak with the company on your behalf.
8. What is the process and timeframe for exercising the first claim?

Make notes of your questions for your insurance provider before you call.

While different companies will have different required documents as part of the application to exercise benefits, in general, all will require some version of the list below. Some companies will have forms available for download on their website. Others will mail a claim packet to you.

1. Healthcare Power of Attorney document (and possibly an affidavit from the attorney who drew it up if it is older than three years)
2. General statement on reason for need for benefit
3. Authorization for the release of health-related information to the insurance company
4. Survey for physician to complete, detailing clinical needs
5. Survey for family to complete attesting to needs, if client still living at home

How long does it take to get approval? Again, this varies. Some companies process applications and claims quickly; others are known for lots of back and forth. It is recommended to have one point of contact in the family who will be monitoring the claim process so that nothing falls between the cracks. Keep a log of calls and emails and when possible, the identity of the person you spoke with. Be persistent. If you continue to be denied, but feel you have a strong case, it may be worthwhile to reach out to the Department of Insurance for advice.