Long Term Care Claims: Notice, Forms, Proof
Notice of Claim
The provisions in the sample long term care insurance policy clearly state the specific
conditions under which benefits will not be paid. Most policies contain provisions similar to
those outlined below.
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You must provide Us with notice of claim within twenty (20) days after the beginning of any
loss covered by the Policy, or as soon as reasonably possible.
COMMENT: Insurance companies used to be fairly rigid about requiring that claims be
filed within 20 days of the date the claim was initially incurred. However, they soon realized
that there are many situations where it is just too difficult or even impossible to file within
specified period of time. So now all claims provisions say "or as soon as reasonably possible."
This is particularly relevant to those who own long term care insurance policies because a high
proportion of the long term care insureds are either rapidly approaching or have already reached
the age when memory and mental acuity are beginning to decline. Someone suffering from
Cognitive Impairment or some other loss of functional capacity may be incapable of filing a
claim in a timely manner and it may take some period of time before someone else can file a claim
on their behalf. |
Claim Forms
The provisions in the sample long term care insurance policy clearly state the specific
conditions under which benefits will not be paid. Most policies contain provisions similar to
those outlined below.
_______________
When We receive your notice of claim, We will provide You with claim form(s). Your notice of
claim must include Your name, the Policy Number, the type of care, and an address to which the
claim form(s) should be sent. If We do not provide You with claim forms within fifteen (15) days
after We receive your notice of claim, Our claim form requirements will be satisfied if You
provide Us with written proof of the date(s) and exact nature of the charges You have incurred for
Covered Services.
| COMMENT: This puts some responsibility on the insurance company to be timely and
responsive in its work. |
Proof of Claim
The provisions in the sample long term care insurance policy clearly state the specific
conditions under which benefits will not be paid. Most policies contain provisions similar to
those outlined below.
_______________
We will pay Benefits only if We determine that you are eligible for Benefits,
have satisfied any required Elimination Period and We receive your completed claim form(s)
and written proof satisfactory to Us that You have incurred charges for Covered Services.
You must submit written proof of claim to Us, at the address stated on the claim form We
provide You, no later than ninety (90) days after the end of the calendar year in which You
incurred charges. Failure to submit proof of claim within this time limit will result in claim
denial unless it is shown that:
- it was not reasonably possible to provide proof of claim within the time period; and
- proof of claim was submitted as soon as reasonably possible and in no event, except in the
absence of your legal capacity, later than one year from the time proof is otherwise required.
COMMENT: Here again reasonableness is the standard. In the normal course of events it
is expected that you will be able to provide written proof of claim within 90 days of after
the end of the calendar year in which you incurred the charges. But extenuating circumstances may
prevent this, such as you losing your capacity to be responsible for your routine activities and
no one else immediately assuming those responsibilities or the insurance company never sending
claim forms.
The purpose of the Notice of Claim and Proof of Claim time limits is to allow the insurance
company time to investigate the claim while data is still readily available and recollection of
events is fresh. Late notice may hamper an insurer's ability to complete its investigation and
determine whether or not benefits are due. |
To help Us determine whether You are eligible for Benefits or You have incurred charges
for Covered Services:
- We or a person We name may contact You, Your Representative, Your Physician
or other persons familiar with Your condition or with the services You received;
- We may require that You provide Us, or a person We name, with access to Your medical records
to obtain information about Your condition or the services You received. We may not be able to
determine Your eligibility for Benefits or approve a claim for Benefits if We do not
have access to these records; and
- We have the right to require You to submit to Us Your Explanation(s) of Benefits from
Medicare or records from any other source from whom You may have received reimbursement for
the same Covered Services.
| COMMENT: All of the above requirements are designed to give the insurance company the
opportunity to verify the legitimacy of your claim. Asking for access to your Medicare
Explanation of Benefits and to records from other sources from whom you may have received
reimbursement for the same Covered Services is done to make sure there are no
inconsistencies in the claim information being reported by you AND to avoid payment for Covered
Services that are payable by Medicare or others as primary insureds. In other words, all or part
of the Covered Services may not be payable by your long term care insurance company
because, according to the agreed upon rules between insurance companies, your insurance company
may be a secondary payer to Medicare or to another insurer. Put simply, no double dipping.
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