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Long Term Care Insurance 101

Filing A Claim Under A Long Term Care Insurance Policy

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Long Term Care insurance generally has specific requirements for filing claims. If the rules described in the policy are not followed exactly, the claim may be denied. It is advisable to inform people closest to you of any such requirement in advance so they can take the necessary steps if you are unable to.

To start the claim, call your insurer's toll free number and report your claim. If you purchased the policy through a broker, also let him or her know. The company will send a form which includes a part for you and a part for your attending doctor to complete.

If you haven't already signed a waiver of the federal privacy law generally referred to as HIPAA and other privacy protections, you will be asked to sign one now.

In addition, insurers generally require an interview with the insured to assure that covered care as defined in the policy is required (and to get an idea of how long that care will be needed). Most often, the interviewer is an independent person hired and paid for by the company (not an employee). The interviewer will speak with you and assess your needs. He or she will ask questions such as:

  • What is your average day like?
  • What happens when you try to _________ (for instance, go to the bathroom, get out of bed)

When you answer the questions, don't minimize the difficulties. At the same time, don't lie and make them worse than they actually are. Keep in mind that the insurer will be checking your doctor's records and will likely compare what it says you've previously reported and what you say during the interview.

To learn more about how to respond during an interview, see our article about what to do when an interviewer comes calling to check whether a person continues to be disabled who is receiving Social Security Disability Insurance. To learn more, see: When An Investigator Comes Calling.

If your claim is turned down, appeal. The concepts are the same as if you are appealing a claim under a Health Insurance Policy. To learn more, see: Health Insurance: Claims: Appeals

Before hiring a care providing service that you expect to be paid by your Long Term Care Insurance Policy, make sure the service is qualified as required by your insurance company and pre-approved by your insurer. Generally this means being licensed by the state in which you reside. You'll save time if you submit information about the agency when you submit your claim - for instance by sending in a copy of the agency's license.

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