Tracking down and having a copy of the policy is a very important first step toward avoiding a claims denial and also ensuring you get every claims dollar you deserve from your policy. Some policies were purchased 20-30 years ago so this may seem like an impossible task, especially since claims experts don’t recommend starting the claims process without the policy in your hand.

A full policy can be as many as 90 pages. In order to determine exactly what kind of care is covered by the policy, and how to qualify for benefits (sometimes called ‘Benefit triggers”), the entire policy will need to be read and understood.

Many times when you call the insurer they will only send a summary of benefits. While this may be helpful, it is NOT the same as a copy of the policy. A professional claims consultant is experienced in assisting people with acquiring a copy of the full policy.  It is imperative to have a copy of the policy prior to your initial consultation, at which time you will receive a comprehensive review of your policy, benefits, the Elimination Period, and the “benefit triggers” that must be met in order for a claim to be approved.

When you file a long-term care insurance claim can have an impact on how fast you’re reimbursed, or even if you receive any reimbursement whatsoever. Three different situations make someone eligible for long-term care insurance reimbursement:

• You plan to start using long-term care services within the next two weeks.
• You’re already receiving long-term care services.
• You recently received long-term care services and want to claim benefits after-the-fact.

If the documentation doesn’t satisfy exactly the contractual terms of your specific policy, the claim can be denied. If the verbiage regarding the care you are receiving doesn’t match exactly what the policy defines as a covered benefit, the claim can be denied.

Long term care insurance claims are exacting and demanding. And they are unique in the sense that they are initially left up to interpretation. Claims will be denied if the type of care documented doesn’t match the policy’s definition of covered care.

AND A VERY COMMON REASON that claims are regularly denied is if your medical paperwork doesn’t match the specific policy language regarding triggers in your policy. This was the very reason my own mother was originally declined. The information in her medical file did not reflect the reality of her specific needs.

If a claim is initially denied and you believe a claim is valid, you should appeal. Many well-meaning medical providers and claim providers don’t understand exactly what the long-term care insurance company needs to see to approve a claim, and, since the family is also not an expert in insurance claims, unnecessary delays and claims denials happen.

That’s why we recommend first talking with a professional long term care insurance claim consultant.

Long-term care insurance claims can leave policyholders and their families feeling like they are on their own.

Here’s one big reason why: with health insurance and Medicare, doctor’s offices and hospitals have billing specialists whose job it is to put in claim on your behalf. Medical billing codes are standardized, and the patient rarely has to get involved.

A long-term care insurance claim is totally different. All the paperwork – from a variety of sources (physicians and caregivers) must be assembled by the patient or their family.

It’s the responsibility of the family to understand the policy enough to know if the supporting documentation will match the specific requirements in their policy, allowing the insurer to pay the claim. Otherwise, the family has to push back on providers to clarify and perhaps amend the documentation to both be accurate and to provide the insurer with what’s needed.

Many insurers require documentation be faxed to them; sometimes that can mean faxing 100+ pages.

Confirming receipt of important paperwork can be frustrating, with hours spent on telephone hold.