It is no secret that the claims process of a long term care claim is frequently frustrating and confusing. Many of the insurers who originally sold the policies are no longer in business or have discontinued writing new business. In our opinion, this affects the claim process.
Clients frequently come to us with the same complaints: The carriers have lost their claim submission on multiple occasions, they repetitively request more information on a piecemeal basis, and/or the claim denial does not give an adequate explanation of the reasons for the claim denial. The following are some tips for submitting a claim which will also assist you and your attorneys if you ultimately file suit over a claim denial:
1. All communications should be in writing and keep a copy of all documents you receive or send to the insurer. If you do speak to a claim representative on the phone, obtain their name. Keep a journal of all oral communications so that you can accurately re-create what has occurred in connection with the claim.
2. Carefully review all claim paperwork before it is submitted. A LTD claim requires a physician to specify a “plan of care.” Usually, there is an area on the attending physician statement form where the “plan of care” is to be specified. The plan of care should detail what type of care is required and for what period of time, i.e., “home health aide, 7 days a week, 12 hours a day.”
3. If you are seeking benefits for care rendered in a facility, i.e., a nursing home or an assisted living facility, check the facility’s license before you submit the claim. Many older policies will not pay benefits for an assisted living facility. In addition, if the policy requires that a nurse “supervise” the facility, ensure that the facility you have chosen meets those requirements.
4. If you are told that the Policy has lapsed for non payment of premiums, consult with an attorney immediately. Most policies have protections against an unintended lapse. However, there may be a time limit on obtaining a reinstatement.
We have helped many, many clients recover the long term care benefits to which they are entitled. In our experience, meritorious claims have been denied as a result of careless claims handling. We are experienced in identifying where the claim adjuster mis-handled the claim and can assist you or your loved one in recovering benefits.