How To Make A Long Term Care Insurance Claim

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How To Make A Long Term Care Insurance Claim

Insurance Personal Finance Author: Admin


Acquiring long-term care insurance is one of the smartest moves that you will make in securing the years ahead. However, what’s more, important than applying for it is actually making use of your benefits. And this will only be possible once you have filed a claim and it gets approved.

Usually, long-term care insurance benefits are claimed years after the policy is acquired. Even so, remember that the process requires a series of steps and important details you need to take note of. That’s why it’s crucial for a policyholder to know how the claiming process works even in a very general sense — as early as the acquisition phase.

Making a claim on your long-term care insurance entails a different process altogether.

This may require time, but it doesn’t have to be burdensome. In fact, you can make it as swift as possible. All you need to do is go through the steps accordingly.

Review your Policy

Once you think you’re eligible to claim your benefits, your initial instinct would be to contact your insurer right away. Though this is a part of the claiming process, what you need to do first is get a hold of your policy and review what’s included in it.

Before you make a claim, these are the features of your long term care insurance that you need to take note of:

Benefit Triggers

Conditions that trigger long-term care insurance benefits can vary from one policy to another. Generally, though, benefits are usually prompted by medical conditions, cognitive impairment, or functional difficulties. Usually, if you can’t perform two or three activities of daily living (ADL) such as bathing, eating, getting dressed, or transferring; have injuries or sickness that medically requires extensive assistance; or cognitive conditions such as dementia and Alzheimer’s, you are eligible to file a claim.

Elimination Period

Long-term care insurance policies are usually built-in with elimination periods. This timeframe refers to the period that you will have to wait before your policy kicks in. This starts right after you triggered your benefits, meaning, you’ll need to pay your initial care expenses from your own pocket. As a policyholder, you have the choice of how long this would be. Typically though, the majority goes for a 90-day waiting period.

Apart from knowing how long your policy’s elimination period is, you need to determine how the days are counted against it. If it’s counted based on calendar days, days will be continually deducted beginning on the date that you have triggered your benefits, regardless of your received care on some days or not. Meaning, if you have a 90-day calendar-day elimination period, your benefits will begin paying off exactly 90 days after your benefits are triggered.

Meanwhile, other elimination periods only count service days. Meaning, they only count the number of days that you actually received care. If you have a 60-day waiting period yet you only receive 3 days of care in a week, your elimination period can last by more than 2 months.

It’s important for you to know how the company counts your elimination period. This way, you’ll know how much you’ll pay from your pocket and when your benefits will start paying off.

Care Providers

Be clear on what care settings your policy covers. Though it’s true that long-term care insurance can pay for a variety of care providers, you need to understand that not all policies are the same. Some policies are only designed to pay for nursing homes, while others are tailored to pay for both nursing homes and in-home care. Go back to what’s written in your long-term care insurance and see what it covers specifically. If it pays for in-home care, does it require a certain certification for your paid caregiver? Will it pay for care services rendered by a loved one? Be clear on these details before you avail of the services of a particular provider and make a claim.

If you already have a care provider yet they don’t meet the requirements of the insurer, you may need to change your caregiver. If not, find out how they can get certified and get them on that program.

Contact Your Insurer

Once you determined that your situation meets your benefit triggers and the insurer’s requirements for your care provider, you can now contact your insurance company. Meanwhile, even if your elimination period is not yet over, you can already get in touch with your insurer in order to get the claims process rolling.

Upon contacting the insurance company, they will give you an instruction on how you will file a claim. Generally, you need to fill up a claim form and submit requirements such as documents from your physician and a plan of care from your care provider. Based on your insurer and type of policy, insurers may require more information from you.

If your policy will cover care coordinator services, it’s a smart move to take advantage of this. Care coordinators can help you in the claims process and create a care plan that best matches your cover. In addition, some insurance agents can also guide you in this process.

The requirements that you need to accomplish in this process can be overwhelming. That’s why it’s best to take advantage of the assistance that a care coordinator or insurance agent can give you. They can help with the more technical aspects of the claim such as the necessary paperwork, while you can focus on the quality of care being given to you or your loved one.

Submit the Information Needed

The insurance company needs information in order to validate your claim. Generally, the information needed to process a long-term care insurance claim should come from three sources: the policyholder, the physician, and the care provider.

As a policyholder, it is your responsibility to take a hold of your long-term care insurance as well as the policy application form which is usually attached to the policy itself. Furthermore, you need to fill out forms as instructed by your insurance company.

Meanwhile, your physician also needs to write a certified statement to prove that the care treatment you receive is warranted by a medical condition. Likewise, your care provider needs to submit a record of the care you’re receiving. These documents will show the extent of care that you need and will help the company determine if you’re already eligible to receive your long-term care insurance benefits.

To make the claim process speedier, make sure that information from all sources is consistent with each other. This will make solidify your claim and will leave no room for doubt on the side of the insurer.

Apart from the documents mentioned above, you can be also required to submit additional papers and records. For instance, if you own a reimbursement type of long-term care insurance, you may need to present the receipts of all care expenses you incurred before your insurer pays off your benefits. Since this is the case, it’s important that you keep every piece of paper in relation to your care needs and ongoing claims process. This way, you have enough data to substantiate your point should discrepancies arise in the future.

Get Assessed by the Insurance Company

After you’ve filed your claim, your insurer will look at the forms and documents you’ve submitted to determine if you’re really eligible to get your benefits. Apart from this, insurance companies usually interview their claimants either through phone or through a visit done by their designated nurse. In this interview, the extent of your care needs will be gauged depending on your physical and cognitive abilities.

During the assessment process, it’s important that your caregiver or a family member is present. This way, you can ensure that the information that would be reported back to the insurance company is accurate and true.

If the insurer finds that the information you gave and the assessment report are sufficient to prove your claim, you will not have a problem getting your benefits. If in case the insurance company needs more verification, they may ask for more information from you. If you organized and kept every piece of paper relating to your care requirements and insurance claims, you will not have a problem with this.

Meanwhile, if the company finds that you are not yet eligible, you will receive a denial letter stating the reasons behind the company’s decision to decline your claim.

What Happens When my Claim Gets Denied?

When you receive a denial letter from your insurance company, don’t just easily resort to paying out of pocket or other financial means to cover your care expenses. It’s important to remember that you can appeal a denial and in the end, you can still get benefits out of your long-term care insurance policy.

If your claim gets denied, here’s what you should do:

  • Gather all the documents such as your policy, claim form, records from your care provider or facility, a statement from your physician, denial letter, communication log between you and your insurer, and any other document related to your claims.
  • Review all these documents. Read the denial letter once again. Afterward, go through your insurance policy again and see if it supports your insurer’s denial. If not, try to analyze the language of your policy and see if you and your company understand it the same way.
  • Seek legal advice. Go for a lawyer whose expertise is on long-term care insurance. With their guide, you’ll know the denial is actually reasonable or not based on all the records you have. If it is and it shows that you actually triggered your benefits yet or receiving care from a certified care provider, you already have a strong argument. With all the necessary documents to back up your point. You can raise this concern to your insurer through an appeal.
  • Explore the “alternate plan of care” option. If your policy has this, you can try to use this option as a basis for your care. This area of coverage is actually designed to be vague. However, claiming benefits from this is usually tougher than those who are grounded on definite policy clauses.


You may have to deal with a lot when it comes to making a long-term care insurance claim. And it can be overwhelming. However, this doesn’t have to be the case for you. In fact, you can make the process smooth and fast by doing the following.

  • More than being adequate, the information you give should be consistent with each other. This way, the insurer will find it easy to prove your claim. Furthermore, you can provide more information than your insurance company requires. Just make sure that they are parallel with the rest of the requirements and will help in making your claim stronger.
  • Clearly understand the language of your long-term care insurance. Sometimes, claims get denied because of mere oversights in interpreting the policy’s wording. This way, you’ll know if you’re already eligible for your benefits or if you can rightfully appeal should the company denies you your claim.
  • Take advantage of care coordinator services. Having a care coordinator will make the claims process easier for you. They can help you in devising a plan of care and finding the right care setting or provider that will match your requirement as well as what’s written in your policy.
  • Educate your family about your policy because it’s likely that one of them will file the claim on your behalf. If they know what’s covered in your long-term care insurance and how the claiming process goes, they will be spared from the stress and being overwhelmed.
  • Buy from a reputable company. When you purchase from an insurer that has strong financial wellness and background, you can rest assured that it will not leave the business and would still be in operation by the time you make a claim.

One of the things that concern people about long-term care insurance is making a claim. It’s normal because they must have heard bad stories about claims getting denied and people ending up being forced to pay from their own pockets. However, this is a very rare occasion because to date, the largest long-term care insurance claim is at $1.8 million and more than 264,000 people have received their benefits in 2012.

During claim time, keep in mind that as a consumer, you have a responsibility too as a consumer and that is to make sure that all information is accurate and that you’re making a claim that’s supported by what is actually said in your policy.