Processing Claims: Physical Examination, Denials, Payments

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 have the right to have you examined by a healthcare professional at Our expense and to conduct an on-site assessment. We may not be able to determine Your eligibility for Benefits or to approve a claim for Benefits if You do not consent to an on-site assessment, if such assessment is needed.

COMMENT: Proof of claim is a two-way street. If a physical examination is deemed necessary by the insurance company, the company ponys up the expense. Refusal to consent to the exam and allow access for an on-site assessment can jeopardize any progress for settling your claim.

Notice of Approval or Denial

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 send you a written notice of Our decision to approve or deny your eligibility for Benefits or a claim as soon as reasonably possible. In no event will We send this notice later than ten (10) working days after We have received all the information We need to assess Your eligibility for Benefits or claim. If You are not eligible for Benefits or We do not approve your claim, Our notice will state the reasons for the denial.

COMMENT: You have an absolute right to know the insurance company’s reason for deciding you are not eligible for Benefits or why your claim was denied. You may have information the insurance company is not aware of which, if they knew, would cause them to reverse their position. The goal is to find the truth, not to approve or deny the claim.

Appeals of Denials

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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If We deny Your eligibility for Benefits or your claim, in whole or in part, We will review Our decision if You or Your Representative:

  1. request in writing that We review Our decision; and
  2. send this request to Us within sixty (60) days after You receive Our denial.

Within Sixty (60) days of the date We receive Your request, We will review the denial and make a final decision. Our final decision will be in writing, and if it is a denial, it will include Our specific reason(s) for the denial and make available all information directly relating to such denial.

COMMENT: If the insurance company affirms its denial of your claim on appeal and you are still unhappy with the decision, your best step is arbitration or mediation where an impartial expert will help resolve the dispute. Then, if a fair settlement cannot be reached, you may decide to hire an attorney and sue the insurance company for breach of contract and, in certain cases, possibly for extra-contractual damages, such as compensatory or punitive damages. How far you are willing to go in challenging the claim denial with the insurance company will depend to a large extent on how serious you believe its error was and your credibility.

Payment of Claims

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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If We approve Your claim, We will immediately pay the Benefits under the terms of the Policy. All Benefits will be paid to you, unless they are assigned by You. Any unpaid Benefits due to you at Your death will be paid to Your estate, unless assigned.