If you have long term care insurance and you are struggling to care for yourself, it may be time to submit a claim. Even though you may qualify for benefits under your policy’s definition, your insurance company will likely try to poke holes in your application and look for any excuse to avoid or delay paying the claim. For this reason, it’s essential that you strategically collect and present evidence to make the strongest possible case of why you qualify for benefits, and submit a strong and well supported claim the first time around.
Read and Understand Your Policy
If you do not have a copy of your long term care policy, request one from your insurance company or broker. Read the policy thoroughly to make sure you understand what services are covered and what is needed to qualify for benefits. Typically, benefits are triggered if you can no longer perform either two or three of the six activities of daily living (ADLs) or if you suffer from a cognitive impairment. ADLs include bathing, eating, dressing, toileting, continence, and transferring. Different policies often define ADL disability and cognitive impairment in slightly different terms, so be sure to understand if your function level meets your policy’s definition of disability.
Get a Medical Evaluation
To make a claim, you will need to document and prove your inability to perform two or more ADLs and/or a cognitive impairment. This includes getting a diagnosis from a qualified doctor who specializes in treating the disabling condition. A diagnosis of dementia, for instance, should come from a neurologist or geriatric psychiatrist. Similarly, if arthritis prevents you from performing ADLs independently, this diagnosis should come from a rheumatologist. Your doctor should take a medical history and perform applicable tests, such as MRIs, X-rays, CT scans and blood work, along with a thorough clinical examination, to support the diagnosis and provide objective evidence to strengthen your claim. You should discuss your ADL limitations or cognitive impairment with the doctor, who should include this information in a detailed report for the insurance company. If you suffer from cognitive impairment, your treating doctor should consider neuropsychological testing as an appropriate diagnostic tool, which can provide substantial support to help you obtain benefits.
In addition to a doctor’s evaluation, you should hire a nurse or physical therapist to visit your home to observe as you perform ADLs, so that this practitioner may document your limitations. Note that for intimate activities like dressing and bathing, the required motions can be mimicked while you remain fully dressed.
Beware that there is a tendency among older adults to underreport their disabling conditions out of embarrassment or forgetfulness. Be sure that a trusted family member or friend is present for the evaluation to ensure the observer gets a complete picture of the situation.
Statements from the Claimant/Family Members
In addition to reports from healthcare practitioners, include a detailed personal statement about how your disability affects you on a daily basis. Statements from one or more family members/friends about their observations of your limitations, such as your need for assistance with specific steps associated with certain ADLs, can provide further documentation of your disability.
Provide Notice of Claim
When you are ready to initiate a claim, file a notice of claim with the insurance company. The insurance company will then send you a claims packet. The claims packet must be filled out thoroughly in accordance with the timeline specified by the insurance company.
Consult Legal Counsel
Before submitting your claim and as early in the preparation process as possible, consult with an attorney with proven experience in long term care insurance claims. In prior decades, insurance companies oversold long term care policies for prices that were not sufficient to support the benefit payments that they are on the hook for today. As aging policyholders come forward to claim their benefits, insurance companies are looking for any loophole they can exploit to cut their losses and avoid paying. An experienced attorney can examine the language of your policy and ensure that your claim contains the proper support. The attorney can ensure the thoroughness of all of the elements of your claim, from your physician’s report to supporting evidence. Further, your attorney can strategize ways to strengthen your claim; for instance, while cognitive impairment can trigger benefits on its own, showing that it also impacts the performance of multiple ADLs could strengthen the claim. Finally, an experienced attorney can help ensure that you dot all of your I’s and cross all of your T’s.
If you are considering filing a long term care insurance claim, or if your claim is being challenged or has been denied, give us a call. We regularly and successfully represent clients with long term care claims and have the experience, knowledge and tenacity to make sure insurance companies keep the promises they made to you or your loved one.
Contact us today for a free consultation.
Evan S. Schwartz
Founder of Schwartz, Conroy & Hack