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Long Term Health Insurance Issues

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Considerations to Make Sure you Receive your Benefits

As people live longer and longer on average, long-term care is a term that has become ever more common in the modern vernacular.  The ideal situation is that health and mobility

come along with an increased lifespan, but the reality is that assistance will likely become necessary at some point and might be necessary for an extended period of time. 

Purchasing and maintaining a long term care insurance policy is one option that many people choose to help cope with the financial challenges which will arise when expensive care is required. 

If you are looking into receiving your benefits, you’ve navigated past the choices on whether or not to obtain the insurance, chosen among many competing packages, and are at the point where you need those decisions to pay off.  Here are some items to consider to ensure that the benefits of having a long term care policy are realized to the extent that you anticipated.

Benefit Triggers and Elimination Periods

Two criteria are universal in receiving the benefits of long-term care insurance regardless of the type of insurance you purchase.   Your benefits will have benefits triggers and an attached elimination period.  The benefits triggers include your physical and mental condition as determined from information gathered by an assessment conducted by a nurse or social worker.  This description of your condition will include your activities of daily living (ADL) and any physical or cognitive impairment that would keep you from completing these activities. 

A significant cognitive impairment or one or more physical impairments which prevent you from independently engaging in two or more of your ADLs are the triggers which allow you to file a claim for benefits from your long-term care insurance.  The insurance company assesses your impairments and then develops a Plan of Care which  outlines and implements the benefits of your long-term care insurance to get you the care you need. 

Your receipt of long-term care benefits is also determined by an elimination period, which is a period between your benefit triggers and when your insurance company starts paying for your care.  Like a deductible on other types of insurance, the elimination period is the portion of your care which has been set aside as your personal responsibility.  The more costly the premium you have paid, the shorter your elimination period should be.  These periods usually range from 60-100 days where you are expected to receive care and pick up the tab before your insurance benefits kick in.

Avoiding Claim Denial

The first step to avoiding the denial of your long-term care insurance claim is to ensure your Plan of Care set up by a physician is consistent with the services paid for by your insurance policy.  The activities of daily living which you are unable to complete are activities which dramatically and directly affect quality of life: bathing, dressing, eating, using the toilet, etc., are all essential activities to maintaining independence, but claim forms do not always let you tell the whole story.  Include as much evidence as you can about your condition and the limitations you experience.  The more details and specifics you can provide for your carrier, the better.  Don’t just describe what you cannot do, but also describe how these limitations impact your life.

Review your claim form carefully to ensure it is as thorough and free of errors as possible.  Review the form with your physician so he can certify the form and so he can suggest any changes which may need to be made.  Beginning with the claim form, all communication with the insurance company should be in writing whenever possible.  Save all correspondence, write down names of those you speak with and follow up with written correspondence recapping everything which was discussed.  Send all written correspondence via certified mail so that it may be easily tracked.

We would always like to think that insurance companies act in good faith and pay claims on a timely basis.  Unfortunately, many insurance companies have a reputation for taking advantage of the cognitively impaired, elderly, and infirm, taking advantage of the vulnerable to stall claims as long as possible in hopes that the claimants get discouraged and give up.  They have also been known not to advise policy holders as to the benefits they are entitled to, deny receiving correspondence or required documents, employ biased doctors and nurses to justify claim denials, and simply interpret your policy language in their own best interests.

In addition to the aforementioned tips, never be afraid to include an advocate in the process.  Someone who is on your side and can make sense of the process can offer guidance and deter insurance companies from trying to take advantage of you.  An advocate can also help you determine if there comes a point when you should retain an attorney.   

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