Your Long-Term-Care Claim has been Denied
If you receive a long-term-care (LTC) claim decline letter, please read it carefully. The insurance company should provide a written explanation explaining why the claim doesn’t meet the policy eligibility requirements. Don’t be reactive. You aren’t going to like the decision, but review the reasons as objectively as possible. Then put it away for a few days and read the letter again.
Call the Benefit Analyst (BA) if you still don’t understand why the claim was denied. This is not a time to be rude. Stick with the facts. Does the insured actually need assistance with two or more Activities of Daily Living (ADLs) as defined in the contract?
A good, and experienced, BA will already have called and talked to you about potential claim decline and why. That is your opportunity to provide objective medical evidence, or tell the BA where to find it.
What to Do if You Disagree with the Decision
If you still disagree, begin with the appeal process that also should be outlined in the letter. Your insurance company usually will want an appeal in writing and it should include the reasons why you feel the decision is incorrect. Again, stick to the facts related to why the claim was denied. Once you’ve addressed those specific issues, then you can include other information that may be pertinent to the insured’s overall need for assistance.
Please understand that talking about Incidental Activities of Living (see Part 1) will not help the case for benefit eligibility. It can’t be said often enough that the contract you bought is specific about eligibility. You must need assistance with two, or more, Activities of Daily Living to be benefit eligible.
The BA who made the decline decision did not make it alone and will not be the one to review the appeal.
State Insurance Departments
If all else fails and you still believe the decision is not a good one, you can access your State Insurance Department’s complaint process. Please do not go here just because you don’t like the decision. Your insurance company will provide the facts they used to make the decision to the State (they have already provided it to you) and the State will respond. I can say from experience that a complaint filed with the state does not mean that the denial will be automatically overturned. As always, the facts will be reviewed by all concerned.
Going through a claim decline is upsetting. But it should not be a reason to cancel your policy or hate all insurance companies. It can be a tool as you now have a better understanding about how to properly access benefits in the future.