Since 2003, my company has provided care for hundreds of clients. Some of those
clients had long term care insurance (“LTCI”) coverage to help pay the cost of that care.
We have helped more than a hundred clients file LTCI claims, and so we’ve been able
to watch and learn to learn some of the best things you can do to avoid having LTCI
companies delay or deny your LTCI claim.
An aside is in order before we start, by the way: despite the things we’ll say in this article
about how difficult it can be to file LTCI claims, we believe that LTCI coverage is a good
thing to consider. It can be an important part of your family’s financial planning and you
should ask your financial advisor about it if you haven’t already done so.
The Most Important Things to Remember When Filing LTCI Claims
1. Choose one person to be in charge of filing the claim. Usually, this will be a
2. That family member in charge of the claim will need the insured person’s
authorization to speak with the insurance company about the claim. A “Power of
Attorney” document will often be sufficient.
3. The family member in charge of the claim will also need some key data: the
policy number, the insured’s date of birth, and the insured’s social security
4. Make sure you have a complete copy of the policy and that you read it before
beginning to file the claim. The policy may contain provisions that can either
increase, decrease or bar benefits from being paid and knowing about such
provisions can help you decide what information to present with the claim, and
how to present it.
5. Get help in filing the claim from someone who knows what to do and how to
do it. Ask the facility where the insured person will be a resident if they have
someone who will help you. You can also ask the agent who sold the policy to in
the first place, but in my experience the agents are better at selling policies than
they are at helping to file claims under those policies.
6. Make sure the claim is complete when you submit it, including all forms and
required supporting documents. Most insurance companies will delay claim
approval by initially disclosing only a partial list of the documents that they will
eventually require. Therefore you should ask for the entire list when you first
notify the insurance company that you want to file a claim.
7. Get the claim filed immediately. The insurance company will take a lot of time to
review the claim once you file it, so don’t delay.
8. Be prompt, thorough and detail-oriented in all your dealings with the insurance
9. After you have submitted your claim, call the company at least once each week
and ask about the claim’s status. Be thorough and thoughtful in asking questions
and writing notes, and be sure to include the date and time of each call, the
telephone number that you called, and the name of the person that you spoke to.
Why Would Insurance Companies Make It Difficult To File Claims?
Insurance companies are not allowed to be dishonest, but they are also not required to
help you “perfect” your claim. All they have to do is allow you to file a claim and then
pass judgement on whether or not your claim has proven that you are eligible for benefits
under the policy.
They are free to create complicated and difficult claims submission and approval
processes, and some of them have claims procedures that almost seem like they were
designed on purpose to confuse, discourage and delay claims.
Why would they do that? For one thing, if they don’t have to pay benefits, they keep the
premium money and have higher profits. Also, the longer they get to keep your money
before paying benefits, the longer they have to earn investment income from those funds.
What If The Insurance Company Sends A Nurse To Assess The Insured’s
By the way, some insurance companies send a nurse to make an assessment when you
file a claim. Remember, that nurse is there as a representative of the insurance company.
The nurse is not your friend. Do not confide anything to the nurse that you do not want
the insurance company to hear. That nurse’s role is to determine whether or not you are
eligible for benefits based on your condition.
What If I Don’t Have A Copy Of The Policy?
If you don’t have a copy of the policy, you should request a copy from the insurance
company. But wait, there are some “tricks” to remember about this request: ask for a
complete copy, including:
• The policy itself
• All riders, endorsement, attachments and anything else affecting benefits,
eligibility and coverage
• The schedule of benefits
• The original policy application filled out by the insured person
Sadly, we’ve seen a few cases over the years where families requested copies of policies,
and then later found their own original copies, and then found that the copies that the
insurance companies sent them were incomplete or just plain wrong. When that was
the case, the errors in the documents provided by the insurance companies always were
errors that would have resulted in lower benefit payments or elimination of benefit
Remember, it’s up to you to make sure that you understand the policy and the claim
process. It probably should be the insurance company’s responsibility to help you, but
they probably won’t so you have to be proactive and thorough and document every step
that you take. If you do that, you should prevail in the end and receive approval of the
Copyright © 2014
by Tim Colling
Article by Tim Colling exclusively for Assisted Living Directory
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