Claims for care via Long Term Care Insurance (LTIC) are generally made by older seniors as that is when they need the care. But older seniors are the least able to manage the complex claims process. They may have fully understood the policy when it was purchased, but it is now 10, 20, 30 or more years later. Submitting a claim for the first time correctly and having it approved can be difficult and time consuming – but critical.
Recently, we had a couple in their 90’s who purchased a policy 20 years ago and needed to trigger it. Many policies that were purchased 20+ years ago have benefits that are not available to new customers today. My client is one of those lucky people. They have a “spousal” policy which allows one of them to use the others benefit if their benefits are used up. Of course, any claims processed under the spouses name reduces that person’s benefits by the amount used, which can be up to 100%.
So, they have the money for care but still had to start the long and complicated process of filing claims for reimbursements. After several months of navigating the claim system with help from their family and us, the reimbursements are now being paid on a regular basis.
There are keys to making this process easier. One of the most important ones is the designation of a “family coordinator.” This person can be the senior, a family member, friend or someone like The Seniors Answer. The coordinator should be well-organized and detail oriented. They must be available to make and receive the many calls from physicians and the insurance company. They need to track and document all calls, emails and any other correspondence including a summary with the date and time of the interaction. The person must be completely objective, focusing on the issue(s) at hand and not emotional. They will need to be authorized by the policyholder to interact with all parties necessary.
The policyholder and family coordinator should read the entire policy. All contact information in the policy must be up to date. They should make a list of questions to ask the insurance company about things not listed or clear in the policy.
They must understand what triggers the benefit and whether the insurance company requires two or three of the six acts of daily living (ADL’s) to do so. As most readers know, the six ADL’s are: bathing, dressing, eating, transferring, toileting and continence. There is a second way to trigger a policy which is cognitive impairment – when a person may be physically able to perform activities but is no longer capable of doing them without help. Cognitive function tests are often substituted as benefit triggers for this trigger category.
The policyholder and family coordinator must understand the benefits. There are a wide range of terms in policies. Some of the items to look for and consider are:
- Elimination period
- Benefit period
- Total benefit pool
- Benefit for different types of care and residences
Once it is determined that it’s time to start the process obtain all forms and verifications needed. When completing the form, fill in every item. Do not use “not applicable or NA.” Start the documentation process and place all conversations and correspondence into a file. If items requested are sent by fax, call to confirm their receipt. Keep track of physicians, care received and medications. Follow up on all requests to physicians or facilities. Keep the file up to date.
This is just an overview of this complex process. If you or a loved-one have questions or need assistance in this process please let us know.
