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Important Considerations For Long-Term Care (LTC) Insurance Claims

Long-term care (LTC) insurance provides for the cost of care that is often not covered by medical insurance, Medicare or Medicaid and is predominantly used for assisted living or nursing home care.

As many as 70% of those who turn 65 will need some type of long-term care,. A one-year stay in a nursing home averages more than $87,000, although some locations in the country average much higher costs. In New York, long-term care averages $136,000 per year, while in Alaska, the same care can cost as much as $240,000. Even at-home assisted care is expensive, although it does cost less at around $50,000 per year. For this reason, many people turn to long-term care insurance. However, if you want to be sure your claim is paid, as was the case for more than 264,000 people in 2012, there are three important steps you must take.

Counting Days For Deductible

Most long-term care insurance policies have a deductible period, which is known as the elimination period. According to our New York/New Jersey disability attorneys, this period can be anywhere from 30 to180 days. The key factor, however, is how the insurer counts those days.

Some policies use calendar days so that payment begins the day the elimination period expires after the claim is filed. For example, if the insurer requires a 60-day deductible period and the insured enters a nursing home on January 1, the insurance company would begin paying the claim on or around March 1.

However, some plans use what is known as service days rather than calendar days. If the insured uses home health care, for example, and the aide only comes three days per week, it would take up to 20 weeks for the claim to be paid if the policy had the same 60-day waiting period. Some insurers will waive the deductible period for home health care, while others do not. Whatever the waiting period may be, experts recommend filing a claim as soon as it is apparent that a problem may require long-term care.

Most Important: Know the requirements of your LTD policy, and get advice from an experienced LTC attorney about how to comply with those requirements.

Disability Requirements

Our New Jersey and New York disability attorney says that the person who will be entering long-term care must be disabled. This means that they are cognitively impaired or need help performing two or three daily activities necessary for health and well-being. These are referred as the Activities of Daily Living (ADLs). These activities include things like cooking, bathing, dressing or eating. One recommendation is that a physician prescribes home health care or long-term nursing care. The doctor’s report should specifically state what the policy requires to qualify someone as disabled. For example, if the policy states that a person qualifies for long-term care if they can no longer step in and out of the shower alone, the doctor should write that into the report.

The more criteria the patient meets, the more likely the claim will be approved. The insurer will make contact by phone or in-person to verify that the insured needs care and an advocate for the patient should be present when that happens. The insurer should also be informed, in writing, that they are to contact the patient advocate and not speak to the client alone. It is common for patients with Alzheimer’s Disease or other form of dementia to have moments of clarity and deny they need any assistance.

Type Of Coverage

Before choosing a caregiver, it is important to check the policy to see what type of health care aide is covered. Some policies will only cover licensed aides who work for an agency, although not all states have such laws. All discussions with the insurance company should be documented and follow-up calls, emails, letters or faxes are encouraged if it appears that the insurance company is slow to pay the claim, say our New Jersey/New York LTD attorneys.

Hire A Long-Term Care Lawyer In New York And New Jersey

If you or a loved one has long-term health care insurance and your claim has been denied, despite following these three steps, contact Uscher, Quiat, Uscher & Russo, P.C.. We have much experience in matters involving LTD insurance coverage. Don’t go it alone! Get the expert advise you need to make certain that you receive the insurance benefits for which you paid. Call us now 201-781-5645.