The request started simple enough … “Kay, I’m overwhelmed at work, and trying to navigate my mother’s long-term care insurance claims is exhausting. Can you help?”
I hear this a lot. The promise that LTC Insurance will help cover medical expenses is very true and real. The act of starting claims, navigating billing, understanding denials, and advocating for what you are owed is often overwhelming for caregivers and incredibly convoluted.
To be fair, I do have several clients where the LTC plans work well, and there are only minor matters to chase. I even have a few that have reaped hundreds of thousands to pay for their care. Most of these plans were purchased decades ago and most were Federal Employees.
In this most recent case, the adult family caregiver was totally frustrated. The company had told them that she didn’t need to pay the annual fee any longer because she activated her claim and was receiving services for home care after being diagnosed with dementia. Most policies stop billing you for the insurance policy once you activate the claim. Then, a year later, they receive a bill for over $7,000 because the LTC Insurance company mistakenly waived her annual fee. Then all claims stopped getting paid. Within a month of the first bill, they get a cancellation notice.
All of his happened before I got engaged. The LTC Insurance company said they could not reinstate the benefits because it had been 60-days since they received the cancellation notice. I was initially hired to just help get the claims reimbursed for the prior year.
Some key things for claims processing may include:
- Medical forms signed by their doctor listing a diagnosis and care needs. These typically have to be done every 4 to 6 months.
- Invoices, caregiver notes, and a license from the Home Care Agency. If you use a family caregiver there are other hurdles to traverse and often they reimburse non-agency caregivers for fewer hours. Typically you will want to do an “Assignment of Benefits” to allow the Home Care Agency to submit the claims and get paid directly. You will however be responsible for any fees not covered and should understand this WHEN you are starting services so you are not surprised with a huge invoice.
- A policy in good standing. It must be paid up to date. Most plans waive annual fees once you start your LTC claim.
When I took the assignment, I read the policy and in it found a “Reinstatement Clause” that said if the individual was diagnosed with a cognitive issue she had up to 9 months to reinstate her policy. They initially told me 60-days had passed and after “checking with the manager” there was no option around this matter. I directed the agent to read this clause — and all of a sudden was given the steps we needed to take to have them review the request.
One week later, my client is told the policy is reinstated and now has hundreds of thousands of dollars available to help pay for mom’s care. Pleased!
If you are the one working to initiate the claim or navigate the claims process, be sure to read the policy. If you need help, there are many daily money managers like me that can help you. To find one near you, visit www.AADMM.com.