You might think that once your long-term-care claim (LTC) has been approved, you have no further obligation and that the insurance company will just keep paying until policy benefits run out. Not necessarily so.
Deductible period/elimination period (EP/DP). For LTC policies that have an EP/DP, this is the amount of time that must pass before the policy starts paying. It could be anywhere from zero to 100+ days and is usually based on dates of service received, not the amount of time that has passed. Often it must be satisfied within a specific period of time. For example, if you have a 20-day EP/DP that must be satisfied within 90 days, it will never be satisfied and the policy won’t pay if you only receive services once a week.
Some people stay on claim due to serious chronic conditions (such as Parkinson’s or severe Alzheimer’s/Dementia). However, there are illnesses or injuries where a reasonable expectation of recovery is present. For example, an insured could recover from a broken hip, a stroke, or a heart attack.
If you are no longer receiving assistance with activities of daily living (ADLs), and only need assistance with housekeeping, meal prep, or yard work, call the insurance company to avoid potential overpayments that must be reimbursed.
Your insurance company will also periodically review a claim to determine whether the insured remains benefit eligible. This is not because they are trying to get out of paying a righteous claim. It is because people do recover.
There are times when an assigned benefit analyst (BA) and a claimant don’t get along. This is not because the BA is incompetent or the claimant is impossible to deal with. Just politely request that a different BA be assigned.
If your policy requires bills as proof of loss, continue to send them in. Again, the contract is between you and the insurance company. They are not obligated to chase after bills every month, although some will, strictly as a courtesy. Even if arrangements have been made with a home healthcare agency, they do not always submit bills timely.
A claim could be underpaid or overpaid. Underpayments are self-explanatory. If it occurs, contact the insurance company and let them know. It will be fixed.
An underpayment or overpayment can also happen if the policy pays a different daily benefit for assisted living or nursing home stays. Always notify the insurance company if the insured changes location, even temporarily to a hospital. Particularly during the EP/DP.
If an overpayment occurs, an insurance company will require repayment. Two other likely causes for overpayments are:
- Benefits are paid when an insured is no longer eligible;
- The policy has a Medicare non-duplication clause. As above, always notify the insurance company if the insured changes location.
The insurance company also has clear responsibilities. But you can avoid problems, and fix them quickly once they occur if you pay attention and keep the lines of communication open with your Benefit Analyst.
The intent of these articles is to serve as a guide through the long term care claim process.
See Part 1
See Part 2
See Part 3