• Mary Sizemore

Best Practices for a Long-Term Care Insurance Claim

Over the last 25 years, I have seen my fair share of claims. They have mostly been from these medical conditions; Alzheimer’s or dementia, Stroke, unstable gait or mobility issues, Macular Degeneration, Cancer, and Parkinson’s. The claim’s departments at the carriers are well-versed to handle your client’s claim but as insurance advisors, we should be preparing our clients for this next step.


Here are a few best practices to assist your client when it comes time to file a claim:


Review the Policy:

Your client may have purchased this policy 10-20 years ago. Take time to review the benefits in depth. This conversation should include the responsible party or power of attorney. Additionally, explain how the elimination period works for home care, as well as, facility care.

Determine the Client’s Level of Dependency:

Do they meet the 2 out of 6 Activities of Daily Living (bathing, dressing, eating, toileting, continence, and transferring)? Is their condition expected to last 90 days or more? Do they need assistance with their Instrumental Activities of Daily Living (managing medications, housekeeping, paying bills, etc). Assistance with IADL’s alone does not meet the benefit trigger.

Do they have a severe cognitive impairment? Or are they classified as MCI (mild cognitive impairment)? MCI does not meet the benefit trigger of the policy, unless their dependency includes assistance with the ADL’s listed above.

Make sure their provider is covered under the policy. Some states require licensure for home health care agencies, assisted living and skilled nursing facilities. It’s important that they meet the policy definition for that particular line of care. Is a family member or friend providing the care? Is that covered under their policy? If they have a “cash” benefit this may not apply

Prepare the client for an in-person assessment:

Due to Covid, many carriers have waived the requirement for an in-person assessment temporarily. Instead, the carriers are relying on medical records and a telephone interview.

In-person Assessment/Telephone Interview: Usually, a registered nurse will visit or call the client to see what their level of dependency is. We have had a few clients, tell the nurse, “that they were fine and didn’t need care”! Obviously, this statement would hinder the claim’s process and causes lots of frustration with the family of the person needing care. Advise your client to be honest – if they need care, there is no shame in that. After all, this is why they purchased the insurance.

Medical Records: Are your client’s medical records up to date? With a chronic illness, your client’s level of dependency can change rapidly. It’s important that their doctor is aware of their care requirements and that the responsible party is communicating with the doctor’s office frequently.

Referral to the Carrier Claim’s Office:

Once you have reviewed the policy and determined your client’s level of dependency, you should refer the client to their carrier’s claim department. A claim is usually started over the telephone. The carrier will mail forms such as a HIPAA for the client or POA to sign. Once they receive these forms back, they can start ordering any necessary requirements. It’s important to make sure these forms are thoroughly completed and returned promptly.

While carriers vary, a typical long-term care insurance claim review should take 30-45 days.


If you have any questions that I can assist you with during your client’s claim review, please do not hesitate to contact me. 1-800-945-1953

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