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.

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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.

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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:

  1. it was not reasonably possible to provide proof of claim within the time period; and
  2. 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 proofof 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:

  1. We or a person We name may contact You, Your Representative, Your Physicianor other persons familiar with Your condition or with the services You received;
  2. 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 Benefitsif We do not have access to these records; and
  3. 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.