Every Detail Matters When It Comes to Filing an Effective Claim

Making a claim is one of the most important aspects of being a policyholder of long term care insurance. After paying years of premiums, the claims process is the time when your policy should fulfill your purpose and pay for your anticipated care expenses. By following these simple tips, you will create an action plan that will hopefully lead to a successful claim and, ultimately, payment.

1. Review Your Policy

It may seem obvious, but the first thing you should do is carefully review your long term care insurance policy. Pay careful attention to the available benefits and how to qualify for them. Look at your policy’s elimination period and see if it will count calendar or service days.

For example, if your elimination period is 90 calendar days, it will end exactly 90 days after you have triggered your benefits. If, however, it is based on service days and you receive care only three days per week, your elimination period does not necessarily end after 90 days.

Also pay close attention to the types of benefits available. Does your policy include only benefits for nursing home or assisted living expenses or are you also eligible for home health care benefits?

Lastly, what event triggers your benefits? Is it not meeting two or three of your Activities of Daily Living (ADL) or requiring Substantial Supervision? How does your policy define the triggering event? Review your policy’s definition section carefully.

2. Contact Your Insurer

After you have reviewed your policy, be sure to contact your insurer with questions. Contacting your insurer BEFORE you or a loved one’s admission to a facility or when home health care is delivered is important. Every insurance company has its own process for filing a claim and preparing necessary paperwork, as well as arranging for an assessment that could be critical to ensuring payment. Planning ahead can avoid unnecessary delays in payment and also alleviate possible confusion about covered benefits.

If your family member is assisting with your claims process, ask the insurer for necessary releases so that others may talk to the insurer on your behalf. Some insurers require an “Authorized Representative” designation or a release of information. Be sure you have all the insurance paperwork needed to file your claim.

3. Stay Organized

Compiling the necessary paperwork for your insurance claim will likely include a lot of documents, including medical records, medical assessments, and insurance documents. Create specific file folders to keep your paperwork organized. Also, make sure you take detailed notes of your telephone calls in a specific notebook dedicated to these conversations.

Gathering information can feel overwhelming. Try taking thorough notes, including date, time and name of the person with whom you spoke, as those notes and information can prove to be critical later, should a dispute arise. Some of the documents you will need may include:

• Your policy
• Insurance releases or Authorized Representative Designation
• Physician’s recommendations
• Occupational Therapy Evaluation (if ADLs trigger the benefits)
• Psychological Evaluation (if cognitive deficit creates the need for benefits)
• Care Plan
• Receipts and invoices for care costs
• Communication logs
• Provider records

4. Enlist the Help of Others

Coordinating insurance coverage can feel overwhelming, especially in the midst of increased health care needs and a significant life transition. Ask for help. Your care coordinator, for example, can help create a treatment plan that matches the writing in your policy. Also, a family member or friend can help organize your paper work and help you create an action plan for necessary follow-up.

If your loved one is already admitted into a facility, there may be an advocate on site to help you navigate the process and collect facility records.

5. Submit All Information Your Policy Requires

Unfortunately failing to submit all necessary paperwork can cause a delay or denial in payment from your insurer. If you or your family member submits incomplete documents, the insurer may not have enough information to evaluate your claim. To help the process move smoothly and swiftly, make sure all needed information is given.

Having supplemental documents, which are not necessarily asked by the insurer, can also be helpful should they ask for more information. Make sure all your information is consistent and contains an accurate reflection of your current health care needs.

Questions?

If you have any questions about the tips laid out above, call our experienced lawyer. We have focused experience handling long term care insurance disputes, and can guide you on the best path. You can reach us online or you can call us today at (651) 788-0236.

Disclaimer: The information in this blog post (“post”) is provided for general informational purposes only, and may not reflect the current law in your jurisdiction. No information contained in this post should be construed as legal advice from Wrobel & Smith, PLLP or the individual author, nor does it create an attorney client relationship. It is not intended to be a substitute for legal counsel on any subject matter. No reader of this post should act or refrain from acting on the basis of any information included in, or accessible through, this Post without seeking the appropriate legal or other professional advice on the particular facts and circumstances at issue from a lawyer licensed in the recipient’s state, country or other appropriate licensing jurisdiction