How To Help Clients Through The LTCi Claims Process

More often than not, people don’t like to admit they need help with things they once did for themselves. This often happens with those requiring Long-Term Care, once they need assistance they rely on their family to provide for them.

What happens when the family care giver can no longer be of assistance? What happens when they get too burnt out or their abilities have been surpassed by the amount and type of care needed?

Once that final step has been taken and the caregiver realizes they need extra assistance, they usually file a claim.
Here’s how it works…
Assess Benefit Eligibility: This is the time when the insurance company checks to make sure the insured is eligible for care. Usually this is when a health practitioner determines the insured is chronically ill and needs help with at least two of the six activities of daily living for a period that is supposed to last at least 90 days or if the health care practitioner determines the insured needs constant supervision due to severe cognitive impairment
Submit Notification: If you feel your client meets the eligibility criteria you can notify the insured’s insurance company that a claim is being made. Notification should usually be made within 30 days of the onset of the need for care or as soon as reasonably possible. Notification can usually be made by mail or telephone and should include the insured’s name and policy number as shown on the policy schedule
Then what?
  • Once the notice of claim is received by the insurance company, a claim form is then sent to the insured. The form should be returned along with a provider’s bill to document the proof of loss.
  • Then the claim is evaluated to verify the insured meets eligibility requirements. Often an assessment is scheduled or the insured’s health care practitioner is contacted to verify medical records.
  • Once the claim is valid, a case manager will work with the insured’s family or caregivers to determine appropriate types of care.
  • After the policy’s elimination period has been satisfied, benefits will be paid to the insured or their care provider.
Although there is a good chance that the LTCi policies you sell today won’t have claims for years to come, it is also possible for an illness or injury requiring LTC services to strike one of your clients tomorrow.
It is best to be prepared and understand the claims process so you are fully prepared to help your clients put their LTCi policies into action.
For more information about LTC or the claims process, contact your LTC Specialists today.