Navigating the complexities of Long Term Care Insurance
Many of our clients have prepared well for themselves and have made sure that they are secure in the years of their retirement. They have the necessary legal documents in place such as their living will, Health Care Proxy and Power of Attorney. A handful of our clients have the good fortune of purchasing a long-term care insurance policy when they covered a significant amount of long term care needs, fully expecting that once they needed the care, it would be covered.
What we come across as care managers, oftentimes is that once they need to use their long-term care insurance policy, that they have spent years paying into, they have difficulty figuring out how to navigate activating it. Most policyholders believe that it is as simple as picking up the phone to file a claim. However, they find out is that it is much more complicated and confusing than that. By the time they are eligible to start receiving the benefit, they are already experiencing health decline that is often combined with a cognitive impairment making it nearly impossible to collect their benefit.
A client said to me recently, “My husband has this long term care insurance policy, but it is so confusing and I am stressed out enough having to try to care for him, I just can’t deal with it”. Long hold times, eligibility criteria, elimination periods, it is truly enough to make you want to pull your hair out! People don’t have the time or patience to manage the details involved. Since the insurance companies are a business and certainly benefit from unused insurance, you can imagine that there are hoops to jump through.
Expect that when you call the insurance agency you will be placed on hold, so come prepared with patience. Then, you will be asked a series of questions and a nurse will be sent out to assess the claimant. Many policies specifically state that in order to be eligible you will need to meet specific criteria. Each policy is unique, so you need to read carefully and understand the stipulations. Most commonly, in order to meet the eligibility criteria, you will need assistance with ADL’s (activities of daily living): these include bathing, dressing, toileting, and eating. Some policies state that a diagnosis of “severe cognitive impairment” will qualify you. This one can be a gray area and more difficult to prove. When submitting the claim for cognitive impairment, this has to be documented by a health-care professional, such as your primary care physician, with any supporting evidence such as tests or imaging.
What comes to most people’s surprise is that the definition of the elimination period is the number of days of which a person needs and is receiving care, before the insurance company will begin paying or reimbursing for the services. Elimination periods can span from 30 days up to 120 days so make sure to check your policy so you know what to expect.
On top of all of this, many of the long-term care insurance agencies, allow themselves a certain length of time to review anything that has been submitted. I recently have assisted multiple clients with obtaining their benefit, every time something was submitted to them, they allowed themselves 10 business days to review the information, whether it be invoices or medical information, approving care providers or facilities. Another client I recently assisted was denied her claim, after months of the spouse submitting invoices, and thinking they would be reimbursed. I assisted them in appealing this decision and was able to gather all of the medical information that solidly had diagnosed her with severe cognitive impairment. But because the information they received initially wasn’t enough she had been denied. After submitting the appeal, I was told that they have up to 30 days to review the appeal before giving a determination on the benefit. They took ALL 30 days, but in the end, they did approve the claim and started paying out the benefit. Just expect that getting reimbursed with not be instantaneous.
In sum, here are some tips to consider when attempting to activate your policy:
Understand your long-term care insurance policy and its requirements to activate.
Recruit the help of family, friends or a professional to assist in the steps to activate your policy to ensure you are going through all the proper steps and submitting all necessary documentation and invoices.
Be persistent and don’t give up!
Happy Fall!
Rhiannon Stare, RN, CDP
Aging Life Care Professional, Riverside Care Advisors
