Tips to Get Your Long-Term Care Insurance Claims Approved and Paid

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Contributor, Benzinga
March 9, 2022

Millions of seniors have purchased long-term care insurance over the past 30 years.  This special coverage is designed to reimburse or pay for qualifying care that is needed as one ages.  Covered benefits can pay for care at home care, in an assisted living facility, or a skilled nursing home setting.

When care is ultimately needed, getting a long-term care insurance claim submitted and paid is not always a simple process.  Unlike health insurance or Medicare, claim processes are not uniform.   With both of these, doctors’ offices and hospitals have billing specialists whose job it is to submit claims on your behalf.  Medical billing codes are standardized, and the patient rarely has to get involved.

This is not the case when it comes to long-term care insurance claims.  The following are some tips to help should you or an aging loved one with coverage face needing care. 

Long-Term Care Insurers Pay Claims

Currently between 6 and 7 million Americans have some form of long-term care insurance coverage.  This protection is generally purchased between ages 50 and 70 with claims typically occurring when policyholders reach their 80s and 90s.

In 2021 some $12.3 Billion was paid to over 336,000 individuals with coverage according to the American Association for Long-Term Care Insurance (AALTCI).  The amount has increased yearly according to the organization.  In 2018, insurers paid $10.3 billion to just over 300,000 policyholders.

Everything Begins With The Long-Term Care Insurance Policy

At one time as many as 100 different insurance companies offered long-term care insurance policies.  While many factors are standardized, each company generally had unique policy language.  That contractual wording ultimately governed what the particular policy will pay for.

When care is ultimately needed, the first step is tracking down and having a copy of the policy.  Having the document will ensure that you get every claim dollar you deserve from your policy.  It can also help avoid a claims denial.  A typical policy can range from 35 to 40 pages and you’ll need to read the whole thing to understand exactly what kind of care is covered and how to qualify for benefits (sometimes called “benefit triggers”).

If you think your aging parents may have long-term care insurance coverage but cannot locate a policy, the best place to start is their bank account.  Look for automatic insurance premium payments deducted from the account.

Most Common Reasons Why Claims Are Denied

When qualifying care is needed, prompt repayment and avoiding a denied claim are your main objectives.  Main reasons for denials are providing the insurer with incomplete information.  A second common reason is submitting documentation that does not exactly satisfy the demands of your specific policy.

  Claims can be denied if the type of care doesn’t match the policy’s definition of covered care.  And, claims are regularly denied if your medical paperwork doesn’t match the specific policy triggers in your policy.

If a claim is denied that you believe is valid, you should appeal the denial.    Many well-meaning medical and care providers don’t understand exactly what the long-term care insurance company needs to see to approve a claim.

Finding Long-Term Care Claims Assistance

Considering the complexity of filing a claim request or the amount of time it can consume, a growing number of individuals are seeking assistance.  Professionals generally charge for full-service support with fees ranging from $2,000 to $5,000.

According to AALTCI’s long-term care insurance claims assistance center, experts generally will provide complimentary answers to simple questions.  Because long-term care claims can easily amount to hundreds of thousands of dollars, being persistent and acting early can be well worthwhile.

About Jesse Slome

Medicare Expert – Director Long Term Care Insurance Association, Medicare Supplement Insurance & Critical Illness Insurance Association