If your parent or other loved one bought a long-term care insurance policy, they paid years of premiums to one day cover these sizable costs.
When that day arrives, it usually comes down to you as the caregiver to collect.
“It’s a terribly stressful time. You’re dealing with an aging parent on top of everything in your own life. The last thing you want to do is fight with an insurance company,” says Jesse Slome, director of the American Association for Long-Term Care Insurance (AALTCI).
Join AARP for just $9 per year with a 5-year membership and get a FREE Gift!
The insurance claims process does take some work. But by understanding how to use long-term care insurance, you get through it much more smoothly.
Your first step: Find your loved one’s long-term care insurance policy. If your loved one can’t tell you where they bought coverage, check bank accounts for past premium payments and mail for a bill or letter from an insurance company.
Take note of when premiums are due and how they’re being paid. You’ll need to continue paying them so your loved one’s policy doesn’t lapse.
Once you’re in touch with the company, you can request a copy of the policy. This 20- to 30-page contract spells out what is covered and for how much.
It will lay out exactly when a claim can be filed and for what services, such as whether it covers in-home care options or only a nursing home.
The contract should list contact information for the insurance company’s claims department. You can call and talk to an agent about your loved one’s coverage.
ARTICLE CONTINUES AFTER ADVERTISEMENT
“We help them understand what’s outlined in the policy and the criteria that determine when they are eligible to file a claim,” says Vice President Steve Sperka at Thrivent, a financial services company that offers long-term care insurance.
You may learn that the insurance company no longer serves this market or even exists.
“Hundreds of companies used to sell these policies. Now there are only six,” Slome says. In this case, you would be referred to a third-party administrator, who would still pay the benefits according to the contract terms.
Health & Wellness Dental insurance plans for members and their families See more Health & Wellness offers >This is a number of days that must pass after your loved one starts needing care before the insurance will start paying. It’s like a deductible, the upfront cost you must remit before insurance kicks in.
Ninety days is standard, but elimination periods can range from zero to 180 days.After the elimination period, most policies require covering the costs out of pocket before submitting a claim to get reimbursed. If the insurance company approves your claim, it will pay you back based on the coverage limits.
When speaking to the insurance company, take detailed notes about the discussion, including the name of the person you’re speaking to, the date and the time. You might need this information in case of a denial.
LIMITED TIME OFFER: Labor Day Sale!
Join AARP for just $9 per year with a 5-year membership and get a FREE Gift! Get instant access to members-only products and hundreds of discounts, a free second membership, and a subscription to AARP The Magazine.
ARTICLE CONTINUES AFTER ADVERTISEMENT
If an insurance company denies your claim and doesn’t reimburse you for the expenses, it will give you a clear explanation for the denial, either over the phone or by mail. Most claim denials happen because a policyholder tried filing for something that wasn’t covered, says Slome of the long-term care insurance association.
“Perhaps the policy required using licensed caregivers, but someone hired their friend from down the street,” he says.
Here are three reasons claims may be denied:
1. Type of care. While in-home care options are popular today, these services were not commonly included in older long-term care insurance policies. “These older policies will deny claims for at-home care but … pay for some services, like home improvements for accessibility,” Slome says.
2. Elimination period requirements. People may try to file long-term care claims without meeting the elimination period first because of the often-confusing way policies count days toward the elimination period. Some policies look at service days when your loved one needs care, not calendar days.
If the policy has a 90-service-day elimination period and your loved one needs care only three days a week, the coverage will take 30 weeks or 210 days to begin: 3 days of care a week x 30 weeks = 90 service days.
3. Paperwork. Insufficient or improper documentation is another reason Slome sees. For example, someone files a claim without an invoice from the caregiving service.
“The best way to avoid a denial is by closely reviewing all aspects of your policy and connecting with your insurance agent and/or carrier if you have questions about specific eligibility criteria,” Thrivent’s Sperka says. After a claim denial, the insurer should tell you what needs to change for future expenses to be covered.
If you believe your claim was unfairly denied and aren’t happy with the insurer’s response, you could contact the AALTCI for its free claims assistance service. It will work with you and the insurer to find a solution.
If that doesn’t work, private companies can take over claims processing for you, relieving you of paperwork or dealing with the insurer.
“Many were long-term care insurance specialists who had large numbers of clients. As these went on claim, they started to help and subsequently expanded,” Slome says. “They typically charge one month of contract benefits.” Contact the AALTCI for referrals to agencies in your state providing this service.
The long-term care insurance industry is not actively trying to deny claims, he says. Insurers paid out a record $13.25 billion in 2022. Understanding your contract’s language and properly following the claims process can help ensure that you get a fair payment, even after an initial denial.
