How to File a Long-Term Care Insurance Claim

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Your loved one needs an increased level of care either due to a physical or cognitive impairment AND they have a long-term care insurance policy. How do you file a claim? First, locate the policy or any records of premium payments. Then call the agent or insurance company listed on the documents to see if the policy is still in-force. If it is, find out all the specifics of their coverage, including how you trigger the policy and start receiving benefits.

Typically, to start receiving benefits, the policyholder must need help with at least 2 activities of daily living or help due to a cognitive impairment. Once you have a physical or cognitive trigger, your need of care must be expected to last more than 90 days and a Plan of Care must be established. After you’ve fulfilled your Elimination Period (waiting period), you’ll start to receive benefits.

You’ll want to file a claim after you know your loved one meets the benefit trigger requirements. When you’re ready to file a claim, you will need to obtain and fill out an initial claim packet. Each company’s insurance claim forms will be slightly different, but they usually contain the following five items, although they may have different names.

5 Common Documents Needed:

1. Policyholder Statement

Also known as a claimant’s statement, individual statement, insured’s statement or care support history. These forms will require basic information about the policyholder like name, address, phone number, date of birth, and policy number. It will also ask for explanations regarding the reasons for submitting the claim, including which activities of daily living help is needed with and how long assistance will be required. It usually includes questions related to hospitalization and medical history as well. The policyholder (or their legal representative/agent under power of attorney) must sign this multi-page statement.

2. Attending Physician Statement

This form is completed by the policyholder’s primary care physician (or the doctor at their long-term care facility) and verifies that the care they require is medically necessary. The physician may need to include test results, office notes, medical records and other supporting documentation to this statement.

3. Nursing Assessment and Plan of Care

Most insurance companies will not approve a long-term care insurance claim without a nursing assessment and/or a prescribed Plan of Care. Sometimes these will be included in the physician’s statement mentioned above. The policyholder’s care provider should have a nurse on staff who can conduct and write up this initial assessment, which will include vital sign measurements, demographic information and medical history. The nurse will also complete the Plan of Care, which describes the type of care required in detail. A physician, LPN, or social worker may have to sign to certify this information is accurate.

4. Provider Statement

If the policyholder is currently receiving long-term care services, each care provider like a skilled nursing facility, assisted living community, or in-home care company will need to complete and sign these forms to verify that it is equipped to provide the services detailed in the Plan of Care. Providers will need to submit proof of proper licensure, certification, etc. If the policy includes an elimination period, invoices from current care providers must also be submitted to ensure these days of care count toward the waiting period needed to begin benefits.

5. Authorization to Release Information

This form ensures compliance with the Health Insurance Portability and Accountability Act (HIPAA) and permits the insurance company to collect health care documentation to process the policyholder’s claim. The policyholder or their legal representative must sign this form. If someone is signing this release on the policyholder’s behalf, a copy of their power of attorney or guardianship documentation must be included.

What Happens Next?

Once the application and information are submitted, the carrier will review and make a decision. It typically takes about a month to determine eligibility, assuming the carrier has access to all the information they need.

Most long-term care claims are approved on the first submission, but if they aren’t, it’s usually a matter of getting the correct documents that the insurance company needs, like the Plan of Care, from their doctor.

Once your eligibility has been confirmed, they’ll notify you or your POA.

The Bottom Line

There are documents to complete and a process that must be followed before benefits can be received. Just make sure you follow protocol so that you can start receiving the valuable benefits for your loved one. As an independent long term care insurance specialist, it’s my job and pleasure to be your advocate during the claims process. Be sure to reach out to the agent who sold you the policy so they can help throughout the process.

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