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 or Medicare and is predominantly used for assisted living or nursing home care. Medicaid can also pay for this care, but only if the patient has completely exhausted his/her own financial resources. You cannot qualify for Medicaid unless and until you are financially destitute.
As many as 70% of those who turn 65 will need some type of long-term care. The high cost of long-term care causes many people to turn to long-term care insurance. There are three important steps you must take if you want to ensure your claim is paid.
Counting Days For Deductible
Most long-term care insurance policies have a deductible period, which is known as the elimination period. This period can be anywhere from 30 to 180 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 LTC policy, and get advice from an experienced LTC attorney about how to comply with those requirements.
LTC Requirements
Our New Jersey/New York LTC attorney says that the person who will be entering long-term care must be unable to perform certain activities of daily living. This means that they are cognitively impaired or need help performing at least activities necessary for health and well-being. These are referred to 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. LTC policies generally require proof that a patient be unable to safely perform at least two ADLs, before benefits will be paid. Simply saying that you cannot is often not enough. You must prove it. That requires support from a medical professional who can attest to your capabilities over a long period of observation.
The more ADLs the patient cannot perform, 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 erroneously they need any assistance.
Type Of Long-Term Care Coverage
Before choosing a caregiver, it is important to check the policy to see what type of health care assistance 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 LTC attorneys.
Hire Long-Term Care Lawyers Serving New York And New Jersey
If you or a loved one has long term 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 LTC insurance coverage and can answer any questions you have about the process. Don’t go it alone! Get the advice you need to make certain that you receive the insurance benefits for which you paid. Call us now 201-781-5645.