FAQ’s For Long Term Care Insurance Claims

Doesn’t the insurance company or the agent file the claim?

Policies will al have an 800# listed so that someone can start a claim with the carrier. And some carriers will then take the ball and run with it down the field. They will collect up all the required documents from the doctor(s), hospital(s), rehab unit(s), and care provider(s). Other carriers will not – they will send all of these forms to the address on file and expect that someone (usually Dutiful Child) will take charge of them and follow thru. Your agent will cannot do any of this – or only a small amount at best. This is because all of these activities require someone to have legal permission to access medical records. So either the policy owner him/herself must do it…or their Durable or Medical Power of Attorney (i.e. Dutiful Child!). Further, even with the companies who are excellent about collecting documents for the claim, the ONE thing the company is not going to do is to examine documents to be sure they match each other and/or match the language in the contract. The best chance of success with a claim is if one person grabs it by the smooth handle and makes sure it all matches, that it is all filled out correctly, and all sent to the carrier in a timely manner.

The administrator at the ALF/NH filed the claim for me? Why do I have to do anything?!

The administrator STARTED the claim for you. S/He probably contact the carrier, got current claim forms and filled them out to the best of his/her ability. But if that person has not read the policy – and often they have not – then s/he has no idea what the documents must say to be sure it matches the contract language.

Further, this person doesn’t have legal authority to either pull records from other parties (doctors, hospitals, rehab units) and/or expertise to make sure that everything matches each other and the contract. So administrators and others may initiate a claim – but they are certainly not the ones to track everything thru to completion for you.

But I was told all I have to do is call the 800#?

This is technically correct. As you get ready to file the claim, someone should call the 800# and be sure you have current and correct claim forms in hand (if you have old ones – ALWAYS be sure to ask for the most current forms!). Further, upon filing the claim request form you will have officially initiated a claim. But be prepared! Most carriers (not all…but most) will then shoot back out other documents and requests for information to substantiate the claim and prove medical necessity and/or that the care provider is properly licensed.

So by all means, call the

800#. The claim has to start somewhere…