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The Value of a Claims Advocate The 3 Components of an LTCI Claim Claims Advocacy When filing a claim on a Long-Term Care Insurance policy, it is crucial that your loved one’s needs are represented accurately to the insurance company. Frequently, the information provided to substantiate the policyholder’s caregiving needs does not fully represent the individual’s impairment according to qualifications of the policy. Your loved one has been paying premiums all these years and now it is time to make sure their Long-Term Care Insurance claim is approved. A Claims Advocate (usually a specially trained Geriatric Care Manager or RN) is the most valuable asset you can have on your side when going through this process.


The 3 Components of the LTC Claim Long-Term Care Insurance claims are evaluated on the basis of three sources of info about the policyholder’s care-giving needs. Regardless of the emphasis on any one particular component (or the order in which these are evaluated) the same three components are assessed in each claim. The 3 Components of the LTCI claims are:

1. The care provider’s “Plan of Care” 2. The physician’s medical records, and 3. The insurance carrier’s assessment. Care Provider “Plan of Care”

Physician Medical Records

All care providers (home health care agencies, assisted living facilities, memory care facilities or nursing homes) complete an evaluation of the care recipient’s care-giving needs, level of physical and/ or cognitive frailty, and the services that will be delivered to meet these needs. This is called a “Plan of Care.” Unfortunately, it is rare that care providers thoroughly and accurately document all care needs in light of the specific triggering criteria that allow the individual to collect benefits from their Long-Term Care Insurance policy. Consequently, it is extremely advantageous that the Plan of Care be reviewed by a Claims Advocate prior to submission to the insurance company.

Long-Term Care Insurance companies also review physician medical records to evaluate whether a caregiving need is supported. Unfortunately, medical records also often lack current and thorough information about these needs. The patient’s self-reported information is relied upon, but it is frequently incomplete as elderly patients are reluctant to disclose intimate details, especially those involving private areas of self-care such as bathing, dressing, and toileting. The infrequency of physician visits can further compound this problem. If the impairment is based on a slowly progressive frailty (versus a sudden onset medical need), the family may possess a more accurate assessment of their loved one’s caregiving needs as they see them struggle with inabilities on a daily basis.

Additionally, much of the information used to develop a Plan of Care is gathered from the patient’s self-report and is often not reflective of his/her true needs. Frequently the frail individual over-asserts his or her independence as a way to maintain dignity and to fight to retain that independence. A Claims Advocate can be invaluable in reviewing the Plan of Care to ensure the policy holder’s needs are accurately represented. Despite the fact that hiring a Care Advocate is an additional expense at the time of claim, this small expense has a large reward in knowing that your loved one will be represented accurately.

Claims for cognitive impairments hinge on safety concerns and cognitive testing. Physicians often fail to document needed safety concerns or test for cognitive challenges, as the patient may be quite adept at convincing others that they are independent despite their progressive cognitive frailty. It is strategically important to have a Claims Advocate review these medical records and provide the physician with additional information he/she may need to accurately reflect a level of frailty. A referral to a neurologist may also be needed to complete additional cognitive testing.


Insurance Carrier Assessment Insurance companies also have the right to employ independent RN assessments to evaluate the policyholder’s needs. This is a crucial component, as this assessment is one more way an insurance company confirms the individual’s level of impairment. The frail individual can be vulnerable during this assessment as he or she may have the tendency to assert his or her own independence beyond what may truly be his or her capacities. A Claims Advocate can first assess the needs of the individual (prior to an insurance assessment) and then be present at the time the insurance company performs the assessment to make sure the individual’s needs are represented accurately. A Claims Advocate also knows how the insurance policy works and how to ensure the caregiving needs are reflected in a manner necessary to approve the claim. Hiring a Claims Advocate to represent your frail loved one is the best insurance you can buy.

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The Advantage of a Claims Advocate