How to File a Claim for Long Term Care Insurance

by Linda S. White, MSW, LICSW

Understanding how to access services from your long term care insurance company is as important as knowing what the benefits are or the amount of the yearly premium.  All policies describe the criteria someone has to meet in order to file a claim and receive benefits.  This is typically needing help with two or three activities of daily living (ADLs) or having cognitive difficulties.  If you are wondering whether someone meets the criteria, review the policy and talk with your insurance agent.

What should families do if one of the parents needs to file a claim?  First, they should phone their insurance agent.  Be sure to complete the proper claim form and attach any requested documents.  Make a copy of all correspondence with the insurance company.  The insurance company will have an independent professional investigate the claim and determine benefit eligibility, usually within a week or two.

The insurance company requires all the paperwork (claim forms, medical records, independent review) to be completed before they will act on the claim.  If the insured has multiple doctors, the insurance company will request records from all of them.  Notifying your medical providers that these requests will be coming can help the process.  This is often were the first delays occur.

Maintain open lines of communication.  Regularly check in with your agent or the insurance company and ask if they have received all information they have requested.  Find out if there is anything you can do to assist them in gathering the needed information.

A local long term care insurance company agent and elder law attorneys suggest working with a care manager (CM) throughout this process.  The CM will be able to interact with the agent, medical professionals, and facilities.  This takes a large burden off the family.  Insurance agents come and go and there is no guarantee your agent will still be working for your insurance company when you need to file a claim.  An elder care manager can be a real asset in this situation by being an advocate for you and the family, as the new agent may not have any incentive to help you.

If the forms are complete and the triggers met, the process to receive monies may take one to two months.  Delays are very common.  The insured and their family count time differently as the event is very emotional for them.  The insurance company views claims as a normal process and they handle it in a detached manner.  This can be very frustrating for the family.

Once the claim is approved, the LTCI company will start paying benefits.  The top rated carriers get their payments out in a timely manner.  Payments can be set up to go directly to the care facility if desired.  Delays usually come from the accounting department and generally are related to how the forms for reimbursement are filled out.  Be sure the person filling the forms out knows how to do it correctly to meet the LTCI company’s needs.  Other delays may come from the postal service and backlog at the LTCI company.

If an insured or their family run into problems and gets NO customer service, call the Insurance Commissioner’s office and file a complaint. Your LTCI policy contains an appeals process you can follow if your claim is denied and you feel it was denied in error.

The key steps in making this process easier are working with your agent, keeping communications open, preparing and submitting the information requested in a timely manner and understanding your policy.

Linda S. White, MSW, LICSW, is a former Elder Care Manager and continuing contributor with Medical Rehabilitation Consultants, Inc.  Her practice emphasizes working with seniors and their families to enhance senior independence, identifying and developing options to care needs, and assisting with senior relocation into retirement, assisted living, adult family home and skilled nursing settings.  She is the Regional Chairperson for Senior Services of Washington, a member of the National Association of Geriatric Care Managers and is a frequent speaker on issues of aging.