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.

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.

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.

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.

Case Studies: Long Term Care Claims

Case Study 1: Sarah’s Timely Notice

Sarah, a policyholder with long-term care insurance, experienced a decline in her health and required in-home care services. As per her policy, Sarah promptly provided notice of her claim within 20 days of the beginning of her care needs. This allowed the insurance company to initiate the claims process promptly, ensuring a smoother and faster resolution. Sarah’s case underscores the significance of timely notice and the impact it can have on the claims process.

Case Study 2: Robert’s Accurate Claim Forms

Robert, another policyholder, had been receiving long-term care services for several months. He submitted his claim forms to the insurance company, including all required information such as his name, policy number, and details of the care received. By ensuring the accuracy and completeness of the claim forms, Robert facilitated the evaluation and verification process, expediting the determination of his eligibility for benefits.

This case study emphasizes the importance of providing comprehensive and accurate claim forms to support the claims process effectively.

Case Study 3: Emily’s Satisfactory Proof

Emily, a long-term care policyholder, incurred charges for covered services throughout the calendar year. She diligently gathered all necessary documentation to support her claim, including invoices, receipts, and statements from care providers.

By submitting written proof of her claim within the prescribed time limit of 90 days, Emily demonstrated her eligibility for benefits and provided the insurer with the necessary information to assess her claim. Emily’s case highlights the critical role of proper documentation and timely submission of proof in facilitating the claims evaluation.