Many purchase long term care insurance for peace of mind. That is the selling point of these often pricey policies and the promise made to insureds by their long term insurance carrier. Unfortunately, when an individual has gotten to the point where they struggle to take care of themselves and are forced to admit they need the benefits promised under their long term care policy, the long term care insurance company makes the process complicated, lengthy, and frustrating. The carrier’s financial incentive to “slow walk” and/or deny a claim is quite strong given that the benefit under many policies may exceed $1,000.00 per week. However, there are steps that an insured and their family can take to make sure the process goes as smoothly as possible.
Under the majority of policies, an insured will qualify for long term benefits if they need Substantial Assistance to perform at least two of the Activities of Daily Living or require Substantial Supervision. Activities of Daily Living include Bathing, Continence, Dressing, Eating (ability to feed yourself), Toileting, and Transferring. Depending on the policy terms, benefits will be paid if the insured receives services by a Home Health Care Provider in the home, or at an Adult Day Care Center, Assisted Living Facility, and/or Nursing Home. Many policies require that the home health care agency and other facilities meet certain requirements and certifications. Understanding the policy definitions is vital for a successful claim. Not only does the insured need to be cognizant of the policy requirements, but they need to be able to clearly convey this information to the physician(s) who will be supporting their claim and providing the insurance company with medical proof that assistance is required for two or more Activities of Daily Living (ADLs). Of note is that under many policies Substantial Assistance does not mean only that the insured requires hands-on/physical assistance by another to perform an ADL, but provides that benefits are payable if the insured requires hands-on or standby assistance. Standby assistance means that the insured requires the presence of another person within arm’s reach in order to prevent injury while performing the particular ADL. Thus, when discussing your limitations with your physician it is important that you articulate and document why you are unable to perform certain ADLs without hands-on or standby assistance as the result of your medical condition.
Because most policies require the home health care agency, nursing home, or assisted living facility to meet certain requirements, the insured should get confirmation that the agency or facility they intend to use is acceptable, even before submitting the claim. In fact advising the insurance company that you or a family member now needs assistance should be done as soon as possible so that both the insured and the insurer have sufficient time to obtain and review the information necessary and increase the chance that a claim determination will be made with minimal delay. Most policies, although not all, have an Elimination Period. This is the amount of time the insured must remain eligible for long term care benefits before benefits are payable. During that time, benefits are not payable and in many cases the insurance company pays 7 to 30 days in arrears. Thus, for someone with a policy that has a 90 day Elimination Period, benefits are not payable for the first 90 days they are unable to perform 2 or more ADLs and the first benefit check may not be sent to the care provider for an additional seven or more days. Thus, preparing financially for this gap is something to consider when applying for benefits.
As part of the application process, the insurance company will likely require the insured to complete numerous forms detailing their limitations, require their physicians to fill out forms and provide medical records to support the claim, and request an in person interview with the insured. The information contained on the claim forms is extremely important as it is the basis for the claim review. Both the insured and the doctor should provide as much detail as possible as insurance companies are notorious for misconstruing records and reaching incorrect assessments. Additionally, someone should attend the in person interview with the insured because many people try to downplay their limitations out of embarrassment or pride and/or fail to clearly explain their limitations.
If your or a loved one are considering filing a claim for long term care benefits, have already filed a claim but are still awaiting approval, or have received a denial of benefits please feel free to DI Law Group at (866) 363-3628 for a free consultation or visit our website at www.Dilawgroup.com for additional information. DI Law Group handles claims nationwide. We have successfully handled hundreds of long term care claims and are very familiar with the delay and denial tactics utilized by these companies.