I will be answering this question in three parts; understanding how to qualify, filing the claim and what to do when denied.
Long Term Care Insurance (LTCI) is an insurance product that is designed to help an individual pay for the care they receive when they are sick/infirm/frail. Long Term Care Insurance is NOT health insurance. It really is Care Insurance. To qualify for coverage you must need help with your care.
Generally the LTCI will begin to reimburse for care once help is needed with at least two Activities of Daily Living (ADLs) more than half the time. The ADLs include six activities: walking (ambulating), dressing, bathing, toileting, eating, and transferring (from chair to bed, bed to chair, etc.). As we become sick or infirm we may need help with these ADLs.
To expand on that a little, when you need help with bathing every time, either every day or once a week, that is going to meet the criteria. If you need help with eating, this means bringing the food from the plate to your mouth, not the preparing of the meal. If you need help putting on socks every day, but put on everything else independently that may not meet that criteria, but it could be part of the help you get once you qualify.
Another way of qualifying for payment (reimbursement for care) under LTCI is a diagnosis of confusion/dementia that impairs an individual’s ability to function without directions from others. So if you or your spouse have dementia, you could qualify to collect your LTCI benefit even if the need for help is inconsistent. Sometimes individuals with dementia can use the toilet independently, but can’t find the toilet, so they need help/supervision almost constantly. They may be able to feed themselves, but need prompting to stay focused on eating. They may dress themselves, but wear boots in the house and slippers outside, so they need monitoring or supervision to stay safe.
This change of condition can be an event or catastrophic change, a stroke, a fall where they break a hip, or hit their head. Sometimes this change is more gradual, a slow decline over time making it hard to put a date on when they began needing that much help.
Using this criteria you may find that you might qualify for using the LTCI policy to help pay for care. GREAT, that is why you paid those premiums all those months/years. You will need information like your name, date of birth, policy #, address, etc. You are going to be asked questions about diagnosis, physician, and what type of help is needed at this time. These questions are sort of a pre-screening for the insurance company. They are trying to get at “why you think you qualify?”
So think about that before you call. What are you getting help with? How often do you need the help? Who is it that helps? Have you been hospitalized recently? When did this need for help begin?
In thinking about these questions and the answers you give it is important to run through your answers before you make that call. We like to paint a very optimistic or positive portrait of our self and our spouse. For this purpose you need to be very honest about the needs that you have. How much help is necessary? It is more like thinking of the worse days in the week, not the best days to answer these questions.
So if you feel it is appropriate, pull out the actual LTCI policy and call the phone number listed on the policy. This is how you begin to file the claim. The representative will ask the necessary questions and send a packet of information that needs to be completed promptly and returned to them.
I will pick up next week to talk about filing the claim and more the week after.