Filing a Long Term Insurance Claim: It’s in the Details

Even if you read your policy carefully during the “free look” period and the company answered all your questions satisfactorily, it may be years before you file your first claim. At that time, you should reread the policy and review the requirements stated in the policy as to how and when to file your claim.

You should not rely on directions from your agent on how to file your claim unless you have first cleared those directions with the insurance company claims department. Your insurance contract is with the insurance company, not with the agent. If your reliance on directions from the agent leads to a problem, you may ultimately win a dispute with the insurance company by claiming that the agent was the legal agent of the company, but that can be avoided if you follow the instructions in the policy. Call the insurance company claims department if you have any questions.

Many long term care policies require written notice from the insured to the insurance company within as little as 20 days after the beginning of any care covered by the policy. The company has specific requirements for the notice of claim in order for it to be regarded as valid. The notice must include your name, the policy number, the type of care and an address to which the claim form(s) should be sent by the company. It is important that you abide by these requirements.

You should not rely on your agent to file the claim for you, even though it may seem convenient. Timeliness in filing is important and relying on someone else to file puts compliance with the timely filing requirement at risk. Most policies have wording that appears to give you grace on the 20-day limit when they add “…or as soon thereafter as possible,” but this wording is designed for a situation where, because you are physically or mentally incapacitated, you are unable to file notice of the claim promptly. Relying on the agent and ignoring your responsibility to make certain the notice is filed on time would not necessarily protect you if the agent failed to file on time.

The policy states that once the company receives your notice of claim, the insurance company will provide you with claim forms within a certain number of days after receiving your notice of claim. You must then provide the insurance company with written proof of the date(s) and exact nature of the charges you have incurred for services eligible for coverage under the policy. In other words, you must provide the company with written proof of claim. This is your responsibility and yours alone. The company gives you are given a certain period of time within which to provide this written proof of claim, usually 90 days after the end of the calendar year in which you incurred the charges. Your policy will clearly state that failure to submit proof of
claim within this specified period will automatically result in a denial unless you can show that it was not reasonably possible to submit the proof in the specified period. Even then, a policy will usually state that in no event will a claim be honored, regardless of the reason for delay (including your legal incapacity), if filed later than one year from the time proof of claim is otherwise required. You must be aware of these requirements from the time you purchase the policy, and you should make plans to have a trusted person serve as a back up to your file notice of claim and proof of claim if you are incapacitated.

If you adhere to these requirements, and any others–such as a physical exam or on-site assessment–regarding the processing of your claim and your claim is denied, you can ask the company to review its decision. But this request must be made in writing and it must be received by the insurance company within a specified period of time (usually 60 days) after you receive the company’s written denial of your claim.

As you can see, you must be aware of a number of important details regarding the filing of your claim. If your agent tells you that claim filing is a simple, uncomplicated process or that you should call him and let him do the work, be very careful. You, and not the agent, have the contractual agreement with the insurance company. Therefore, you, and not the agent, are responsible for making certain you comply with the claim filing requirements in the contract you have with the insurance company. If an agent tells you not to worry about the claim filing process, that should be a warning that the agent may not be straight about other aspects of the sales transaction. This is why you must ask questions, read the contract carefully during the free look period and be sure appropriate people in the insurance company home office answer all your questions. You also need to document your questions and their answers so you have a complete record.

There are other avenues of recourse should your claim be denied, such as contacting an attorney who is versed in bad faith insurance contracts or filing a complaint with your state’s insurance commissioner.

Case Studies: Filing a Long Term Insurance Claim

Case Study 1: Timely Notice of Claim 

The Smith family had a long-term care insurance policy that required policyholders to file a notice of claim within 20 days after the beginning of the covered care. Unfortunately, Mr. Smith neglected to provide written notice to the insurance company within the specified time frame. As a result, their claim was at risk of being denied. This case underscores the importance of promptly notifying the insurance company when filing a claim and understanding the specific requirements outlined in the policy.

Case Study 2: Written Proof of Claim 

Mrs. Johnson, a policyholder, incurred significant charges for long-term care services covered by her insurance policy. However, she failed to provide the insurance company with written proof of the date(s) and nature of these charges within the required timeframe, which was 90 days after the end of the calendar year in which the expenses were incurred. Without the necessary documentation, her claim was at risk of being denied. This case highlights the policyholder’s responsibility to provide timely and accurate documentation to support the claim.

Case Study 3: Seeking Review of Denied Claim 

Mr. Anderson submitted a claim for long-term care expenses, but the insurance company denied his claim, citing a provision in the policy. However, the policy allowed policyholders to request a review of the denial by submitting a written request within 60 days after receiving the written denial. Mr. Anderson, determined to seek justice, promptly submitted a request for review, highlighting the errors he believed the insurance company had made.