Long Term Care Insurance – A Stress Test for Claimants!

Man with paperworkYou have a parent about to file a long term care claim.  They have trouble walking.  They need help toileting, eating and moving out of bed.  Premium payments are up to date.

Slam dunk, right?  Not so fast- Many claims are denied.  And, even if approved may take a lot longer with a lot more hassle.

A  New York Times investigation in 2007 found large numbers of  claimants were victims of “unnecessary delays and overwhelming bureaucracies.” A California investigative reporter newspaper stated 25% of all claims were being denied. In 2008, insurance regulators found “a pattern of consumer harm in the company’s long-term care insurance business.”  Since 2008, companies claim improvement in customer service and efficiency.

That’s good news right?  As patient advocates, we are seeing a different picture.

Delays in claim processing

  • Requested documentation is “never received and must be resent”
  • Claim is delayed because your providers (hospitals, MDs, rehab, physical therapists etc) have not sent in their paperwork.

Denial of claims are common!

 Claimant does not meet criteria for need with 2 or more Activities of Daily Life    (ADLS)

Critical  to getting long-term care benefits paid on policies is that the insured                       needs assistance with two or more activities of daily living— eating, bathing,                        dressing, toileting, transferring to or from a bed or chair and continence.

Ineligible Care Provider

Your policy may require a facility or caregiver have a specific license.

Hint – read your policy carefully.  Insurers will insist that a facility meets their current criteria even though that criterion wasn’t specified in the policy you purchased.


  • Review your policy carefully especially the definitions of need for assistance with ADLs
  • Determine when the clock starts ticking. Policies typically include a deductible, known as an elimination period, of 20, 60 or 90 days. Insurers differ on how they count those days.
  • Clearly state what assistance is needed with ADLs
  • Tell your physician the extent of your limitations. Your MD may not realize just how much assistance you need with activities of daily life.
  • Have an advocate (either family member or a professional) present if insurer sends a representative to the home or hospital.
  • Ask home health aides keep daily care notes which will be requested by the insurer
  • Take concise notes on every interaction. Keep fax documentation, synopses of phone calls with names date and times, keep copies of all documents sent and received.
  • Follow up on all faxes or mailings with a phone call to ensure receipt.
  • If asked to send something more than once, document that this is the second (3rd or …) submission on the fax cover sheet or letter.

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