How to File a Claim on My Long-Term Care Insurance Policy

If you purchased a long-term care (LTC) insurance policy and are ready to use your benefits, you can receive the care needed without paying for all your expenses. Some reasons for filing a claim on your policy may include a need for nursing care, physical, occupational, or speech therapy, and help with day-to-day activities. 

While filing an insurance claim can be long and arduous, Referah is here to help guide you through it. Staying organized and paying close attention to details will help make the process easier. This article will discuss what you need to know before filing a claim, the documents required to file, and what to do after you have filed. 

What to Know About Long-Term Care Insurance Before Filing a Claim  

You will want to begin by reading your current policy and noting important parts like eligibility, the benefit amount and how long it will last, the benefit triggers, and the kind of care covered in your policy. You may also want to contact your insurance company and review the policy together, highlighting the essential things you want to know and letting them help you understand your policy document better. 

If you don’t yet have long-term care insurance but are considering it, it’s important to know when to purchase. You can learn more in our related article, “When Should I Get Long-Term Care Insurance?”  

Who is Eligible?  

Some instances when you will be eligible for reimbursements from your long-term care policy and can expect a faster payout is when you plan to use your benefits within the next week, rather than later. If you are considering filing a month later, now is not the best time to file. Another case for eligibility is when you have already had long-term care services and wish to be reimbursed. 

How Much is the Benefit and How Long Will the Benefits Last? 

You will want to know the dollar amount of benefits for the long-term care insurance policy. Some policies may offer a lump sum amount for care services, and others may have a daily benefit sum ranging from $50 to nearly $300 a day for proper care coverage. 

Additionally, you will need to know the length or duration of the benefits. Many policies pay for care per year or even 2, 3, and 5 years, while other policies might offer lifetime coverage.  

What are the Benefit Triggers? 

Long-term care insurance policies have specified conditions for “benefit triggers” that allow you to start receiving your policy benefits. For example, if the policyholder needs assistance with at least two Activities of Daily Living (ADLs), they qualify to start receiving their long-term care benefits. Another trigger for long-term care insurance eligibility is “cognitive impairment,” which will be determined through specific cognitive function tests.  

Insurance companies use different benefit triggers; carefully read your policy and the section describing your benefits eligibility. When doing so, be sure to ask these additional questions before filing a claim: 

• What kind of care does the policy cover? 
• Is there a waiver or premium?  
• Is there an elimination period?  
• Are there coverage exclusions? 
• Is there a death benefit?  

If you are concerned about other financial burdens you may face later in life, consider reading our next article, "Prepaid Funeral Plans." Preparing to handle financial stress on yourself or your family is never too soon. 

Documents Needed to File a Long-Term Insurance Claim  

If you meet the benefits trigger for the long-term care insurance policy, the next step will be to collect the necessary documents to file a claim. Insurance companies may have a few discrepancies in how to file a claim; however, the majority will require you to fill out these five common forms: 

• A Policyholder Statement, claimant’s statement, or individual statement will detail a policyholder's basic information such as name, birthdate, address, policy number, and more. It will also explain your reasons for submitting the claim.  
• Attending Physician Statement is the form your primary care physician must submit stating that you require the type of medical care you say you need. Additional documents such as test results and medical records may also be required.  
• A Nursing Assessment and Plan of Care is an initial assessment of your health that a nurse will complete and have your physician, LPN, or social worker sign for verification. 
• Provider Statement will be completed by your long-term care provider, such as the skilled nursing facility, assisted living community, or in-home care company you use. This form confirms that they can meet your care and service needs. 
• Authorization of Release Information gives consent under the Health Insurance Portability and Accountability Act (HIPAA) and allows the insurance company to review the submitted health care documentation and information. 

What to Do After the Long-Term Care Insurance Claim Has Been Filed  

Final steps include following up with the insurance company and waiting for a decision about the claim status. 

After you have submitted your necessary documents for filing a claim checking with your insurance company to be sure they have all the information and documents required for eligibility is critical. It is essential to submit invoices or receipts from your care provider during the waiting period for a decision on your claim status and after it has been accepted.  

Long-Term Care Insurance Approval Process 

An essential part of the approval process includes your policies Elimination Period (EP). The Elimination Period is defined as “the day you first become disabled and continuing for the period noted in the policy.” So, when you initially choose your policy, you will need to decide how long you want your Elimination Period (or the waiting period from when you become disabled and receiving benefit payments from an insurer), which can be anywhere from 30, 60, or 90 days (about three months). 

Also, it is crucial to understand that the approval process is two steps. The community providing care needs to be approved to meet the criteria outlined in the policy (usually takes 2-7 days), and the policyholder needs to be approved as needing care. The approval process does not stop there, as approval will need to be ongoing. The community must supply regular updates that you still need the specified care and that the community can still provide the necessary care.  

In some instances, residents will move into their senior care community before they have been approved, which can be nerve-wracking and put the initial financial burden on themselves.  

If your claim is denied, you can appeal. You can contact a long-term care lawyer who will help you review your policy, reasons for denial, and your following options. Our article on how to find a good elder law attorney can be the right start when you need legal support.

Find a Senior Living Community Near You

You have thoughtfully purchased a long-term care insurance policy and can now benefit from its coverage. Long-term care insurance coverage will help you financially and can also be an emotional and financial benefit for your future caregivers, such as family members and friends. Carefully review your policy and decide the right time to fill out a claim.

Referah Family Connection Agents are here to help guide you or your loved one when deciding your best senior care options. They can help find the right community for you or your loved one’s needs. We work closely with seniors and their families in communities across the country to help you find professional senior care and support near you.