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The Long Term Care Insurance Claim Nightmare

If you are reading this, your life is anything but fun right now.

You, or someone you love very much, have already… or are about to… submit a claim against the Long Term Care policy they bought decades ago. This process is so convoluted, so non-intuitive, that even the request for the claim forms themselves is a daunting experience.

Fear not.

Here are some simple steps that may well get your claim approved on the first outing.

Get your hands on the actual policy

Sounds simple enough, doesn’t it? But where is that 25-year-old policy? With the Wills? With other insurance policies? Where are important papers stored?

Sounds crazy, but you may have to call the Long Term Care insurer. You can find their name through monthly or yearly premium checks. Have one of your grandchildren go online and search for the company’s latest phone number. (They will know exactly how to do that!)

Call the insurance company and ask them to send a full copy of the policy to the insured at the address of record. Don’t accept a ‘Certificate of Coverage’; demand a full copy of every page of the policy. It may cost a few dollars.

Reach out for the claim form

Once you have a copy of the policy in hand you will have to reach out to the insurance company again and request a claim application.

If you are computer/internet savvy, your fastest route to getting your hands on a claim application is the insurer’s website. Fill out the required information and you may even be able to print the application right on the spot.

However, if computers or internet use are not your strong suite, you’ll have to call the insurance company. Look for their number on the policy, itself. (It has to be there!)

Look for a big, thick envelope in the mail

Its arrival could take a week or two or three.

When you first see all of the claim application paperwork, your reaction may be to put it aside.

Don’t do that.

There’s about 20 pages of the paperwork that mean nothing at the moment.

When all is said and done, your claim itself will probably be about 5 or 6 pages long.

Be neat. Be thorough. Provide all of the information the company asks for… especially the name, address and fax number of the insured’s Primary Care Physician. Make a copy of the entire form for your records.

Write a brief cover letter. In it, name yourself as an ‘Authorized Person’ on the claim. This letter should be signed by the insured… not you… unless you are the insured.

Send the claim application and cover letter back to the company using Certified Mail, Return Receipt Requested. This will give you the signature of the recipient and the date of receipt by the company. (They cannot play the ‘we-never-received-that’ game if you have proof of receipt by them.)

Without delay, call the Primary Care Physician’s office and ask for the office manager. Tell them they will be getting a request for medical records from ‘XYZ’ Long Term Care Insurance. Ask them to please send the records immediately upon request. Tell them you will pay for their expedited response. They will love you.

Three weeks later

You should have the Return Receipt by now, showing who received your claim form and what day/time it was delivered. Call the insurance company. Tell them you have proof of delivery of your claim. Tell them you have been named as an ‘Authorized Person’ on the claim. Demand a status report. If they fail to give that to you, ask to speak with their supervisor. If they fail to connect you with a supervisor, call back and ask to speak with a Claims Supervisor immediately. That usually works.

If for some reason the claim has not been approved, ask why not.

As a rule, the Primary Care Physician’s office may have set the Medical Records request aside. (They are busy saving lives.) Call the Primary Care Physician’s office again and ask to speak with the office manager. Tell them your LTC claim approval is being held up because their office has not yet sent the Records.

Ask that they be sent out that day. This usually works.

Two weeks later

If you have not received the claim approval by now, call the company again and ask for a status. If you are unsuccessful, try this:

Write a letter to the Claims Supervisor and mail it Certified Mail, Return Receipt Requested (for obvious reasons). In the letter, state that if the claim is not approved by ‘X’ date, you will turn the matter over to the State Attorney General’s Office of the state where the insurance company home office is located. (Ex: If the insurance company Home Office is in Illinois, your letter must be sent to the Illinois State Attorney General.) Unless the insurance company feels your claim is absolutely fraudulent, you will probably get an approval in a matter of days.

Your last resort

At the risk of seeming horribly self-serving, you are welcome to approach me.

Feel free to contact me through this website or simply call.

I might be able to help. (I do have a great claim approval track record!)

Or… involve your attorney.

I cost less, but he/she probably knows more than I do.

Your call, of course.

© 2022, Surrogate Son. All rights reserved.


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