Your parents told you “they never wanted to be a burden” and had the foresight to purchase a Long Term Care Insurance policy. But what happens when you or your loved one needs to file a claim for benefits? Often, when people are in the midst of a health crisis, the process of filing a long term claim can be daunting. Our hope is to provide you with some valuable advice for filing your Long Term Care Insurance Policy claim to help get you the benefits that were proactively planned for. Review the Policy: Before initiating a claim it is important to review the policy to get a clear understanding of the terminology and benefits of the individual policy. The face sheet of the policy often gives you a general overview of the policy benefits. The pages that follow, however, are extremely important to read and understand. The verbiage used may be ambiguous and confusing. It is not “by accident” that the language in these policies is at times ambiguous and vague. It is by fully understanding these nuances in policy language that you can maximize your benefit and ensure getting a claim approved which is called “getting on claim”. Speak to a Professional If you do not have the policy in its entirety, calling the insurance agent who sold you the policy is a good first point person. The agent may also give you relevant information about initiating the claim, phone numbers, etc. Now you need to contact the Insurance Company but before you do it’s critical to know what questions you may be asked since this is the way the company determines if the individual meets the long term care criteria. The policy may offer a Care Management Benefit, as well. If it does, determine if you can hire your own or if you need to use theirs. Also, ask if there are any incentives to using the company’s care manager. Keep in mind, they are hired by the insurance carrier and may have their own agenda when assessing needs and developing a plan of care. If the policy allows for an independent care coordinator; take advantage of this option as this person can also be your advocate for getting person on claim. They can ultimately save you time and money and educate you about the process. Even if the policy does not cover the cost of an independent care coordinator, a consultation with a private Care Advisor may be worth considering. What “Triggers” or Qualifies You To Initiate a Claim? Typically, to qualify for benefits a person must be certified by a licensed health care provider (Doctor, Physician Assistant, Nurse, or Licensed Clinical Social Worker) that the person is in need of assistance with 2 out of 6 ADL’s (Activities of Daily Living), or have a significant documented cognitive impairment. All too often during the initial claim process, families might not know the lingo necessary to qualify their loved one for a claim. What NOT To Do When Filing a Claim A big mistake people make are emphasizing IADL’s (Instrumental Activities of Daily Living) care needs such as shopping, cooking, housekeeping, driving, and medication management. Although these issues are noteworthy they are not ‘care needs’ that will qualify for care in the LTC policy. It is essential to communicate the need for assistance based on two of the ADL’s below or cognitive impairment. ADL skills are considered:
- Bathing: washing yourself by sponge bath; or in either a tub or shower, including the task of getting in or out of the shower
- Dressing: putting on and taking off all items of clothing and any necessary fasteners, braces or artificial limbs
- Transferring: moving into or out of bed, chair, or wheelchair
- Toileting: getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene.
- Eating: feeding yourself by getting food into the body from a receptacle (such as a plate, cup or table) or by a feeding tube intravenously
- Continence: the ability to maintain control of bowel and bladder function; or when unable to maintain control of bladder or bowel function, the ability to perform associated personal hygiene (including caring for a catheter or colostomy bag).
- Cognitive Impairment: A deterioration or loss in intellectual capacity which places the “identified person” in jeopardy of harming yourself or others unless they receive assistance. The cognitive loss must be established by clinical evidence and standardized tests which reliably measure: short or long term memory. Impairment with deductive or abstract reasoning; or judgment as it relates to safety awareness.