This blog post is designed to provide general information on the subjects covered. It is not, however, intended to provide specific estate planning, insurance, tax or legal advice. Please note that LTC Consumer and its representatives do not give financial planning, tax or legal advice. You are encouraged to consult with your tax advisor or attorney concerning your own situation.

Long Term Care Insurance Claims – How Do They Work?

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You secured long term care insurance coverage – great! Now, how does it work when you need to submit a claim? Do insurance carriers pay benefits right away? How does the process work?

If you or someone you know is ready to make a long term care insurance claim, here’s how LTCI claims work.

Eligibility

With most LTC insurance carriers, policyholders are eligible to submit a long term care insurance claim when their doctor confirms they need substantial help with at least two out of six activities of daily living (ADLs). ADLs include:

  • Eating
  • Bathing
  • Dressing
  • Toileting
  • Continence
  • Transferring (such as from a bed to a chair)

Policyholders are also eligible if they have a cognitive impairment such as dementia or Alzheimer’s and are a danger to themselves or others. The condition must be expected to last for at least 90 days.

Filing a Long Term Care Insurance Claim

A long term care claim must be approved and the elimination period satisfied before benefits are paid. While not exhaustive, the following steps for long term care insurance claims will help you understand the process.

Step 1

The policyholder or a member of their support team should contact the insurance carrier to get a claim form. Contact information for the insurance carrier is typically on page one of the insurance policy.

If you’re calling for someone else, you may be required to provide the following information:

  • Power of Attorney
  • Policy number
  • Policyholder’s current address and the last four digits of their social security number

To determine if the policyholder is eligible for benefits, the carrier may contact:

  • The policyholder to arrange a visit to review their functional status
  • The policyholder’s care provider
  • The policyholder’s physician
  • The facility where the policyholder lives to gather clinical data about their functional status

Step 2

After a thorough review, the carrier will decide if the policyholder meets the eligibility requirements and notifies the policyholder in writing.

Step 3

The elimination period must be satisfied before benefits are paid. The elimination period is the number of days the policyholder must pay for care while remaining eligible for benefits. This is similar to a deductible and typically lasts 90 days. Review your policy details for elimination period requirements.

Step 4

Covered long term care services may be paid directly to the care provider, or the policyholder may be reimbursed for qualifying expenses they pay for themselves. For reimbursement, the facility, policyholder or a member of their support team must submit invoices for covered services to receive benefits.

Step 5

The insurance carrier will review the claim periodically to make sure the policyholder is still eligible for benefits.

According to a study by America’s Health Insurance Plans, the great majority of LTCI claims are paid.  In fact, only 4% of individuals filing a claim reported that it was declined and this decreases to 2.4% a year after the initial claim.

Long term care insurance offers families peace of mind and financial protection against the rising cost of long term care. Do you and your loved ones have a long term care plan for the future? Get an instant quote for long term care insurance today.

LTC Consumer is an independent, free online service to help consumers understand what long term care insurance is, how it works, and how to evaluate coverage options. Our mission is to provide an educational, no-pressure resource for learning about long term care planning, with the opportunity to speak with specialists who can help them.

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