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Has Your Insurance Company Denied
Your Disability Claim?

Whether an insurance company, employer, union or other ERISA governed
plan has denied your insurance claim, we can help.

7 Steps to Take Before Filing a Long-Term Care Claim

If you or a loved one are in dire need of a long-term care plan, the process of filing a claim can be quite difficult to navigate. Here are some essential steps to take while in the process of filing a long-term care claim.


  1. Designate a family to coordinate the process

Before filing a claim, a family member must be designated as the coordinator of the entire process. This person must be well-organized and have a high attention to detail. They will often need to be available for frequent phone calls with the insurance company, various physicians, etc. The person must not be overly emotional, and instead focus on recording and tracking every single phone call, document, etc.


  1. Read the entire policy

Before filing a claim, it is essential for the family coordinator to thoroughly read through the entire insurance policy. If there are no available copies, then you must call the insurance company and ask them to send you the documents.


  1. File the claim at the first sign of an issue

These policies will typically include a deductible, also known as an elimination period. Different policies will vary in what particular days they will count towards the elimination period before the insurance company will begin to pay for long-term care. Some policies will count all calendar days, while other policies will only count days that the individual receives primary care. Due to this elimination period, it is essential to file the claim at the first sign of a problem in your loved one. The insurance company needs to review all medical records, and a doctor may even have to personally certify that your loved one has a covered disability, which tends to be a time-consuming process.


  1. Know the benefit triggers

Throughout this process, you must be aware of the fact that long-term care payments are typically triggered when you or a loved one cannot perform two of the six activities of daily living (ADLs) without assistance. These ADLs are bathing, dressing, eating, transferring, toileting, and continence. A health care provider should confirm in detail what ADLs cannot be performed, and the level of assistance that is required. Cognitive impairment is also another benefit trigger, which should also be confirmed by a physician in detail.


  1. Study the benefits provided by the policy

Before hiring a caregiver, it is essential to study what type of care will be covered by the policy. This is to avoid discovering too late that the care provided to you or a loved one is not covered by the policy. For example, many policies will only pay for licensed caregivers from a particular agency. Different policies will have different terms for what and where benefits will be covered, therefore it is essential to understand what benefits the policy covers, its elimination period, its benefit period, etc.


  1. Follow-up

Review all of the documents pertaining to the policy, and verify that your loved one qualifies for long-term care under that specific policy. Keeping a log is essential, which includes recording every doctor you’ve seen, all types of care your loved one has received, medications they’ve been prescribed, etc. Once you receive the claim paperwork, it is important that you fill out every single line and insert “not applicable” where it is needed. Submitting a claim correctly, and having it approved is a long and difficult process. If the insurance company delays in its review process, or denies your claim, consider hiring a lawyer to review your case and see if they deem the denial to be in bad faith.

Need someone in your corner? An experienced long term care attorney retained early in the process can assist you with your claim. For a complimentary consultation to review your claim and to learn how we can help you to obtain the benefits you are entitled to, contact us today.

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