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Call today: 720.344.0312 Recent LTC Articles Unraveling LTCI Claims: Don’t let your client deal with the bureaucracy alone. Senior Market Advisor November 2003 By Wilma G. Anderson If you think a successful long term care sale ends with the policy delivery, think again. Once the sale has been made, you need to keep tabs on your clients so that you know when they are considering filing a claim; they will undoubtedly need your expert advice and guidance. With your help, your clients will not only get through the process faster, but will also avoid making bad decisions that could eventually come back to haunt them. Without your help, they can make honest mistakes that will result in benefits being denied or delayed. Three Simple Rules Understanding how benefits are triggered will help a successful claim request move more efficiently. Make sure your clients understand the following three points about LTC benefits: The 90-day Rule For tax-qualified plans, the patient’s doctor must certify on the attending physician’s statement (APS) that the claimant is expected to need care for more than 90 days. If the doctor doesn’t disclose this need, the claim is automatically declined and the process stops right there. This rule is in place because Medicare may provide benefits for up to 100 days of skilled care. For example, Medicare may pay for up to 100 days of skilled care in a nursing home and/or usually up to 45 days of skilled care at home after a hospitalization. Not all doctors are aware of the 90-day eligibility rule, so advise your client to remind his doctor, and make sure that the doctor notes this same information in his client’s medical chart as well. (If your client has a very old LTC policy – one bought prior to 1987 – a three-day hospitalization requirement is the first step for eligibility.) Tell the Truth It’s important not to let clients sugarcoat their situation. Unlike those who file exaggerated auto or homeowners claims, older people often understate their condition in an attempt to appear healthier than they are. Let your clients know that they have to tell the truth to avoid inadvertently convincing the insurer to deny benefits. This can be hard because pride often gets in the way. Focus on helping your client avoid an unwarranted decline letter. Once the insurer has sent someone from a homecare agency or other authorized representative to assess your client, the insurance company receives a report. Once the insurance company has turned down the claim, it won’t reassess just because you and your client don’t like the results. Instead, the company will put a letter in the client’s file detailing why he or she didn’t qualify, which can complicate claims in the future. Imagine receiving a phone call from an upset client who tells you the long term care policy you sold is a scam. The husband needs home care, but the insurance company refuses to pay for it because the company doesn’t think he’s ill enough to warrant paying the claim. “Insurance agents and insurance companies are all the same,” the wife tells you. “When you’re taking our money, you’re all smiles, but then you don’t pay when we need it.” The wife may have a legitimate gripe. Her husband may be ill enough to qualify, but unfortunately, the couple didn’t know how to navigate the claims process and didn’t ask you for help first. When the couple called the insurance company to initiate the claim process, the insurer’s care coordinator called and spoke to the claimant, who put up a brave front, minimizing the extent of his illness. “I’m doing pretty well. I can get around fine sometimes,” he said. What he didn’t say was that most of the time he can’t get around, and so his claim was denied. Another client who attempted to navigate the claims process on her own was Edna, who’s on oxygen full-time. She can barely walk without it, though she removes the tank when she showers. She told an insurer, “Sometimes I can go without oxygen.” The claim was denied. Eventually, we got the denial overturned and benefits approved, but it was a struggle. Another client, Emma, called me first, wanting to know how to file a claim. Her husband, Bill, had been treated for prostate cancer and the side effects were debilitating. A new cancer was discovered later and his health deteriorated. He needed help with transferring (getting in and out of chairs and bed) and toileting – two of the six activities of daily living required for a tax-qualified LTC policy to pay benefits. I called on Bill and Emma and spent 30 minutes explaining the forms to them, showing them where to sign and quelling their anxieties. The claim went through without a hitch and they soon began collecting the benefits they deserved. Hire only Licensed Providers Make sure clients hire only licensed providers. In one case a man needed a hospital bed. One question he was asked was “Have you had any care?” Indeed, he had. A home healthcare worker had been attending to him, but she wasn’t licensed by the state and had not been hired through a licensed home health care agency, so the insurer refused to pay for her services. Sometimes doctors refer patients to unlicensed home care providers. Although some might provide excellent care, that fact is irrelevant in the claims process. Under the terms of most LTC contracts, only care provided by a licensed, bonded individual, such as an RN, LPN or a licensed aide placed in the home by a licensed home health care agency, is eligible for reimbursement. Make sure your clients know this. The insurance industry has many rules that claimants must follow. Your duty is to successfully guide your clients through this bureaucratic thicket. If you do, when they have a claim, they won’t remember what you said when they bought the policy, but they will remember the ultimate outcome. While providing good service at the time of a claim is the right thing to do for your client, it’s also the right thing to do for your business; the good will that you create can lead to new referrals. Keeping in Touch In an ideal situation, long term care clients who must file a claim will call the agent who sold them the policy. Inevitably, however, some clients will call the insurance carrier directly without consulting their agent first, possibly jeopardizing the claim. Prevent this from happening by implementing a systematic program for staying in touch with clients. Use it and they’ll be much more likely to call you when they need your help. To keep your name before your clients, consider making contact with them a minimum of four times a year. This will let them know that you’re there for them without overdoing it. Here are a few suggestions: Everyone likes to be remembered on his or her birthday. Telephone your clients on their birthdays, but don’t talk business. Send a personalized, hand-signed birthday card that includes your business card. Send one holiday card every year. I usually send a Thanksgiving card because it stands out. Plus, you can send it to everyone because the holiday doesn’t have any religious connotations. Send regular newsletters to your clients. Some newsletter services can give you a pre-approved monthly newsletter in electronic format – either on disk or as a file that’s emailed to you. This gives you the flexibility to add, subtract or switch articles very easily. If you don’t want to handle the mailing, you can provide your customer list to a service that will mail the newsletters for you at a reasonable price. Click here to return to list

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