Long Term Care Claim Tips

1. Protect against post-claim underwriting

In all three example states, an insurer of long term care services cannot post-claims underwrite. This means that, if an insurer fails to ask you questions about your health BEFORE you get coverage, they cannot ask you the health questions AFTER you are accepted and use the information to rescind your policy.

It is important to understand, however, that even though an insurer cannot post-claim underwrite, the insurer may have the right to deny benefits or rescind the policy if the applicant lies or does not include all relevant medical information that the insurer requests on the application. (When an insurer “rescinds” a policy, the premiums paid by the policyholder are returned and the insurer acts as if the policy was never in effect.)

Therefore, protect yourself against this when you apply for the policy. Make sure the information you provide in your application is true. And later, when and if you file a claim, be sure you have a good explanation if you answered any of the application questions incorrectly. Often, an inconsistency between your application and your medical history is because you misunderstood a question on an application, or, your agent miscommunicated its meaning, or, you did not know, at the time you filled out or signed to the truth of your answers that you had a condition that would have required a different answer. None of those qualify as fraud.

2. Read your policy, ask questions.

There are many facets to long term care insurance policies, but insurance regulations in all three example states provide reasonable safeguards to make sure that policy details are clearly described. So read your policy, ask questions, and know what our policy covers before you need to know. Which sources of care are eligible for insurance reimbursement? What are the “triggers” that make you eligible for coverage? How much of a waiting period (elimination period) will there be before coverage kicks in? What is the maximum benefit (in dollars and/or in time)? What is the daily benefit? Is there a new waiting period required each NEW time you use long term care? If so, how much time must pass between periods of care in order to activate a new waiting period?

3. Be polite but assertive if a claim problem arises and get help.

Insurance companies are profit-driven corporations. If you or someone you know faces an unfair long term care claim decision or denial, and is not physically or mentally up to fighting back, get help. Seek assistance from family or another healthy, able person who is in a position to negotiate with the insurance company. If the insurance company is still reluctant to pay, don’t be intimidated—get help, and make sure there is no post-claim underwriting involved. If informal dispute resolution efforts fail, file a complaint the insurance regulator in your state and seek help. Sources of help include elder law and policyholder attorneys, and advocates employed by non-profit organizations. And again, review your policy before you need it, so you are not left uninformed when you are the most vulnerable.

4. Make sure you know claim-filing requirements.

Check your long term care policy to find out the deadline for filing a claim and how frequently you need to verify disability in order to get benefits. Knowing the rules is critical in getting your claim paid. Failing to adhere to the rules can give an insurer an excuse for denying your claim.


The information presented in this publication is for general informational purposes and is not a substitute for legal advice. If you have a specific legal issue or problem, United Policyholders recommends that you consult with an attorney. Guidance on hiring professional help can be found in the “Find Help” section of www.uphelp.org. United Policyholders does not sell insurance or certify, endorse or warrant any of the insurance products, vendors, or professionals identified on our website.

Source: https://uphelp.org/claim-guidance-publications/long-term-care-claim-tips/
Date: December 3, 2021