Long Term Care Claims: Notice, Forms, Proof

UPDATED: Jul 14, 2023Fact Checked

Get Legal Help Today

Find the right lawyer for your legal issue.

secured lock Secured with SHA-256 Encryption

Jeffrey Johnson

Insurance Lawyer

Jeffrey Johnson is a legal writer with a focus on personal injury. He has worked on personal injury and sovereign immunity litigation in addition to experience in family, estate, and criminal law. He earned a J.D. from the University of Baltimore and has worked in legal offices and non-profits in Maryland, Texas, and North Carolina. He has also earned an MFA in screenwriting from Chapman Univer...

Insurance Lawyer

UPDATED: Jul 14, 2023

Advertiser Disclosure

It’s all about you. We want to help you make the right legal decisions.

We strive to help you make confident insurance and legal decisions. Finding trusted and reliable insurance quotes and legal advice should be easy. This doesn’t influence our content. Our opinions are our own.

Editorial Guidelines: We are a free online resource for anyone interested in learning more about legal topics and insurance. Our goal is to be an objective, third-party resource for everything legal and insurance related. We update our site regularly, and all content is reviewed by experts.

UPDATED: Jul 14, 2023Fact Checked

Notice of Claim

The provisions in the sample long term care insurance policy clearly state the specific conditions under which benefits will not be paid. Most policies contain provisions similar to those outlined below.

_____________

You must provide Us with notice of claim within twenty (20) days after the beginning of any loss covered by the Policy, or as soon as reasonably possible.

COMMENT: Insurance companies used to be fairly rigid about requiring that claims be filed within 20 days of the date the claim was initially incurred. However, they soon realized that there are many situations where it is just too difficult or even impossible to file within specified period of time. So now all claims provisions say “or as soon as reasonably possible.” This is particularly relevant to those who own long term care insurance policies because a high proportion of the long term care insureds are either rapidly approaching or have already reached the age when memory and mental acuity are beginning to decline. Someone suffering from Cognitive Impairment or some other loss of functional capacity may be incapable of filing a claim in a timely manner and it may take some period of time before someone else can file a claim on their behalf.

Claim Forms

The provisions in the sample long term care insurance policy clearly state the specific conditions under which benefits will not be paid. Most policies contain provisions similar to those outlined below.

_______________

When We receive your notice of claim, We will provide You with claim form(s). Your notice of claim must include Your name, the Policy Number, the type of care, and an address to which the claim form(s) should be sent. If We do not provide You with claim forms within fifteen (15) days after We receive your notice of claim, Our claim form requirements will be satisfied if You provide Us with written proof of the date(s) and exact nature of the charges You have incurred for Covered Services.

COMMENT: This puts some responsibility on the insurance company to be timely and responsive in its work.

Proof of Claim

The provisions in the sample long term care insurance policy clearly state the specific conditions under which benefits will not be paid. Most policies contain provisions similar to those outlined below.

_______________

We will pay Benefits only if We determine that you are eligible for Benefits, have satisfied any required Elimination Period and We receive your completed claim form(s) and written proof satisfactory to Us that You have incurred charges for Covered Services.

You must submit written proof of claim to Us, at the address stated on the claim form We provide You, no later than ninety (90) days after the end of the calendar year in which You incurred charges. Failure to submit proof of claim within this time limit will result in claim denial unless it is shown that:

  1. it was not reasonably possible to provide proof of claim within the time period; and
  2. proof of claim was submitted as soon as reasonably possible and in no event, except in the absence of your legal capacity, later than one year from the time proof is otherwise required.
COMMENT: Here again reasonableness is the standard. In the normal course of events it is expected that you will be able to provide written proofof claim within 90 days of after the end of the calendar year in which you incurred the charges. But extenuating circumstances may prevent this, such as you losing your capacity to be responsible for your routine activities and no one else immediately assuming those responsibilities or the insurance company never sending claim forms.

The purpose of the Notice of Claim and Proof of Claim time limits is to allow the insurance company time to investigate the claim while data is still readily available and recollection of events is fresh. Late notice may hamper an insurer’s ability to complete its investigation and determine whether or not benefits are due.

To help Us determine whether You are eligible for Benefits or You have incurred charges for Covered Services:

  1. We or a person We name may contact You, Your Representative, Your Physicianor other persons familiar with Your condition or with the services You received;
  2. We may require that You provide Us, or a person We name, with access to Your medical records to obtain information about Your condition or the services You received. We may not be able to determine Your eligibility for Benefits or approve a claim for Benefitsif We do not have access to these records; and
  3. We have the right to require You to submit to Us Your Explanation(s) of Benefits from Medicare or records from any other source from whom You may have received reimbursement for the same Covered Services.
COMMENT: All of the above requirements are designed to give the insurance company the opportunity to verify the legitimacy of your claim. Asking for access to your Medicare Explanation of Benefits and to records from other sources from whom you may have received reimbursement for the same Covered Services is done to make sure there are no inconsistencies in the claim information being reported by you AND to avoid payment for Covered Services that are payable by Medicare or others as primary insureds. In other words, all or part of the Covered Services may not be payable by your long term care insurance company because, according to the agreed upon rules between insurance companies, your insurance company may be a secondary payer to Medicare or to another insurer. Put simply, no double dipping.

Case Studies: Long Term Care Claims

Case Study 1: Sarah’s Timely Notice

Sarah, a policyholder with long-term care insurance, experienced a decline in her health and required in-home care services. As per her policy, Sarah promptly provided notice of her claim within 20 days of the beginning of her care needs. This allowed the insurance company to initiate the claims process promptly, ensuring a smoother and faster resolution. Sarah’s case underscores the significance of timely notice and the impact it can have on the claims process.

Case Study 2: Robert’s Accurate Claim Forms

Robert, another policyholder, had been receiving long-term care services for several months. He submitted his claim forms to the insurance company, including all required information such as his name, policy number, and details of the care received. By ensuring the accuracy and completeness of the claim forms, Robert facilitated the evaluation and verification process, expediting the determination of his eligibility for benefits.

This case study emphasizes the importance of providing comprehensive and accurate claim forms to support the claims process effectively.

Case Study 3: Emily’s Satisfactory Proof

Emily, a long-term care policyholder, incurred charges for covered services throughout the calendar year. She diligently gathered all necessary documentation to support her claim, including invoices, receipts, and statements from care providers.

By submitting written proof of her claim within the prescribed time limit of 90 days, Emily demonstrated her eligibility for benefits and provided the insurer with the necessary information to assess her claim. Emily’s case highlights the critical role of proper documentation and timely submission of proof in facilitating the claims evaluation.

Get Legal Help Today

Find the right lawyer for your legal issue.

secured lock Secured with SHA-256 Encryption

Jeffrey Johnson

Insurance Lawyer

Jeffrey Johnson is a legal writer with a focus on personal injury. He has worked on personal injury and sovereign immunity litigation in addition to experience in family, estate, and criminal law. He earned a J.D. from the University of Baltimore and has worked in legal offices and non-profits in Maryland, Texas, and North Carolina. He has also earned an MFA in screenwriting from Chapman Univer...

Insurance Lawyer

Editorial Guidelines: We are a free online resource for anyone interested in learning more about legal topics and insurance. Our goal is to be an objective, third-party resource for everything legal and insurance related. We update our site regularly, and all content is reviewed by experts.

Get Legal Help Today

Find the right lawyer for your legal issue.

secured lock Secured with SHA-256 Encryption