What to Do if Your LTC Claim Is Denied the First Time

Buying a long-term care policy is a big investment and an important step in creating a secure retirement plan. When it’s time to go on claim, the process can sometimes feel foreign and nerve-wracking for individuals during a time when stress and emotions are running high. If your claim is denied for any reason, many individuals are left in a state of panic and questioning.

To help make sure the claims process is an easy one, and to help you understand why a claim could be denied, we’ve gathered a few tips and key advice.

Understanding the 8 Phases of the LTC Claims Process

While the claims process can differ from carrier to carrier, the basic steps are fairly similar. Get to know these eight steps so you know what to expect at claim time.

Need help with 2 out of 6 ADLs: You must have documented proof in your medical records that you need help with at least two out of six activities of daily living (ADLs) or have been diagnosed with a cognitive impairment.
Familiarize yourself with the policy: Get to know the policy features before starting the claims process. If you don’t have a copy of the policy, call the carrier directly and order a copy. If the policy is for a loved one, you may need their Social Security Number and other information to get policy details.
Ask the right questions: It’s ok to call the carrier to get more information to understand the policy details. Filing a claim without knowing how the policy works is like playing darts in a dark, crowded room. Once you understand how it works, you’ll have a higher chance of being successful.
Complete the carrier claim form: Get the claim forms from the insurance carrier, complete the information, and gather any other supporting information to prove your case.
Wait for a response: A caseworker will review the information submitted and decide if the policyholder meets the eligibility requirements to go on claim.
Satisfy the elimination period: Before the policy pays a benefit, you must satisfy the elimination period, similar to a waiting period for disability coverage.
The Carrier pays the claim: After satisfying the elimination period, the carrier will begin paying the claim directly or through reimbursement.
Claim review: The claim will be reviewed periodically to make sure you are still eligible for benefits.

Sometimes, policyholders may experience issues along the way. Generally speaking, the carrier claims departments are there to help you. They can help answer questions and provide information based on your case.

Let us help you navigate the claims process.

What If My Claim Is Denied?

But what if you follow all the steps, and a carrier denies your claim? What do you do now?

If your claim is denied, you must file a formal appeal with required documentation. Your carrier can instruct you on how to do this.

The appeal process can sometimes be long and arduous for busy families trying to cope during an already difficult and emotional time. This process can be handled on your own or by various service providers who offer their support and experience in managing the long-term care appeal process for you.

Amanda Senior care offers free LTCI claims processing, and FSC offers families training programs to increase their chance of first-time claim success by 80%. If you don’t have the time and energy to spare, FSC also offer a professional team who can handle the claims process for you.

At LTC Consumer, we help individuals get covered with an LTC policy that works best for them. Contact us today to speak with an LTC Specialist about your options.