Episode 3: Long Term Care Insurance Claims: The Basics

Firm partners Evan Schwartz and Michail Hack discuss the current state of the long term care industry, some of the basics of filing claims, and what you can do to pursue a claim that has been disputed, denied, or terminated by an insurance company.

Podcast Show Notes

In this episode of the Insurance Lawyer, Evan Schwartz discusses the basics of long-term care insurance with firm partner, Michael Hack. The long-term care insurance industry has changed over the years, beginning  with generous policies including lifetime benefits with cost of living increases and cash reimbursement benefits. Today, the policies are limited and non-cancelable, meaning once you pay your premiums, you keep the policy indefinitely. 

With the many types of long-term care policies that exist today, the newer ones are called reimbursement policies. This is where someone comes in to care for you, they give you an invoice, you submit the invoice to the carrier and then the carrier pays the invoice. Also, there are more generous policies, such as cash policies that give you a daily indemnity when you satisfy the needs of your long-term care. Such policies require a monthly proof of loss, state registration, and a statement of whether you need a state-certified home health care nurse or that you reside in a state-licensed facility, such as a nursing home or assisted living facility. However, you may make an amendment to your cash policy that allows your spouse to stay at home and care for you, in which they get paid the daily indemnity.

One thing to keep in mind with these policies is the policy’s schedule. This determines what benefits you get paid for, and for how long. It also includes the cost of living adjustment. Certain policies will have a maximum amount that they will pay for the entire duration of the policy, while some have no set maximum amount. In that case, your benefits can increase along with the cost of living adjustment as long as you are alive.

In order to qualify for benefits under long-term care policies, you must prove physically and cognitively that you need assistance in the home. For the physical qualification, you must be able to prove that you need assistance with three out of five “Activites of Daily Living” (ADLs), such as bathing, eating, dressing, toileting, continence and transfer. Then a healthcare nurse from an in-home evaluation agency will observe and write a report to issue to the insurance company. For the cognitive qualification, a neuropsychologist will evaluate your brain and how it functions. To satisfy the definition of cognitive impairment, you must show that you are a danger to yourself and that you need someone present to make sure you won’t harm yourself or others. Or, you must show signs of intellectual deterioration, meaning symptoms of Parkinson’s, multiple sclerosis, dementia or Alzheimer’s, or anything else that shows memory loss, processing speed issues, or fogginess.


When applying for long-term care insurance evaluate all of the options, but keep in mind what benefits you would like to qualify for, for how long and the cost of living adjustment. In order to qualify for long-term care insurance, you must prove that you need assistance in daily activities, such as bathing or getting around your home, or that you need someone present to ensure that you do not harm yourself or others.