Frequently Asked Questions about Long-Term Care Insurance Claims

The average age of the U.S. population is rising and many baby boomers already have reached retirement age.  Given these emerging demographics, a growing number of individuals and their families face the challenge of financial planning for the enormous costs associated with long-term care in the event of serious illness or injury.  Although some people can take advantage of public options, many individuals turn to a variety of funding alternatives that include ordinary income, savings, reverse mortgages, and annuities.  Long-term care insurance provides another option for handling the enormous costs associated with ongoing care for an incapacitated individual.  This blog post answers some common questions about long-term care coverage and claims.

Why do I need insurance to cover the costs of long-term care?

Although it is not inconceivable that an individual might pay for long-term care from personal assets, the costs of this type of care make such an approach impractical for many people.  According to the website for the U.S. Department of Health and Human Services, the average cost for long-term care in the United States amounts to $6,235 per month for a semi-private room in a nursing home and $6,995 for a private room.  While the precise cost will depend on a senior’s needs and circumstances, many individuals cannot afford this type of expenditure from savings and assets.  People with such resources typically attempt to maximize the amount of their financial legacy that is available to their surviving loved ones.  Long-term care insurance provides an alternative to depleting an aging family member’s net worth to pay for care.

What expenses will long-term care insurance cover?

While policies vary somewhat, most forms of long-term care insurance are comprehensive.  These policies will provide daily benefits to individuals in a range of settings, such as the insured’s residence, nursing homes, adult day care facilities, respite care, assisted living complexes, and hospice care environments.  This coverage typically provides benefits for the following:

  • Skilled nursing services
  • Personal care (e.g., preparing meals, dressing, bathing, etc.)
  • Rehabilitative, occupational, physical, and speech therapy

What circumstances must occur for an individual to qualify to start receiving long-term care insurance benefits?

There are two key concepts that policyholders must understand about the commencement of long-term care insurance benefits.  The first concept is referred to as a “benefits trigger.”  An evaluation is performed by a social work and/or nurse who completes an assessment form.  The information required to complete the form typically focuses on “Activities of Daily Living” (ADLs) or cognitive impairments.  When you are unable to perform a certain number of ADLs or experience cognitive impairment, these limitations will trigger benefits.

Another important concept that must be understood in terms of eligibility for benefits is the “elimination period.”  This term refers to a time period that must elapse following the benefit trigger before commencement of benefits.  This waiting period can be understood to be analogous to a “deductible” under your health care insurance except that the insured pays through the passage of time rather than money.  The elimination period usually will be 30, 60, or 90 days depending on the policy selected.  Important Caveat: Some policies require a policyholder to pay for services or care during the elimination period to obtain benefits.

If your insurance carrier is refusing to comply with its contractual obligation, you are invited to contact our law firm to speak to an experienced Miami insurance claims attorney.  My law firm specializes in representing policyholders in claims disputes in Miami and throughout Florida. Click here to read about some of our case results.  The Law Firm of J.P. Gonzalez-Sirgo, P.A. offers free consultations and case evaluations. No Recovery, No Lawyer Fees. Call 305-461-1095 or Toll Free 1-866-71-CLAIM. 

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