Filing Long Term Care Claims In San Diego County – How To Do It – Part Three

Filing Long Term Care Claims In San Diego County - How To Do It


In Parts One and Two in this series, we described how to start the filing of the Long Term Care Insurance (“LTCI”) claim and how LTCI companies sometimes delay, and sometimes even avoid, paying LTCI claims.  In Part Three we will describe how important it is to have a copy of the LTCI policy.

You Need To Have A Complete Copy Of The LTCI Policy

It is very important for the family member acting as the “project manager” in charge of filing the LTCI claim to have a complete copy of the LTCI policy, including all pages, with all the policy terms, definitions, declarations page or coverage limits page, and any other written material that the insurance company will use to:

  • Determine whether or not the insured person is eligible for benefits
  • Determine the maximum dollar amount of benefits payable under the policy.
  • Determine whether the In-Home Care Agency, nursing home or other service provider that you plan to use is “approved” to be a provider under the LTCI policy terms.

It might seem surprising that you need this, but in fact we have seen several situations in which LTCI insurance companies denied claims or denied full payment, claiming that the provider was not qualified under the policy provisions.  In all cases that we have encountered so far, after we read the policies we have been able to show them how what they were doing was wrong under the terms of the policy and get them to reverse their decisions.

What If Your LTCI Company Has Been Bought By Another LTCI Company?

One other thing worth mentioning here is that if the policy was issued long ago, the insurance company that issued it may have been acquired by another insurance company (which may in turn have been acquired by another one). There has been a lot of that sort of consolidation in the LTCI industry.  One example of that is the Time Insurance Company, whose LTCI policies and claims are now the responsibility of John Hancock.  Another example is the large number of formerly independent LTCI companies that have been acquired by Conseco.

This sometimes leads to the acquiring company not being able to locate a copy of the specific policy, or of the coverage declarations page for some of the individual policies.  You may have to fight even harder in those cases to get what is rightly due to your elderly insured loved one when that happens, unfortunately.  If that is happening in your case, you may find that when you request a copy of the policy, it arrives with pages missing, such as the declarations page that describes the coverage benefits.

You Need To Have A Complete Copy Of The Original LTCI Application Submitted By The Policyholder

One last thing to remember related to making sure that you have a copy of the LTCI policy is this: policy copies almost always should include a copy of the original coverage application that was submitted by the policyholder, usually as an attachment at the back of the policy.

If you don’t have that, or you don’t receive it with the copy of the policy that you will request from the insurance company, insist that the insurance company send a copy to you.  That will be the best evidence of the types and dollar amounts of coverage that the policy holder originally wanted the policy to include.


So, always make sure that you have a copy of the LTCI policy, including all pages, as well as a photocopy of the original application for the insurance, when you are filing an LTCI claim.  Without those, you won’t be able to know for certain whether the LTCI company is being fair and reasonable in telling you whether or not the policyholder is eligible for benefits, and once payments final begin, whether or not the amount that they’re paying is correct.

In Part Four, the final installment of this series, we will describe how important it is to get your In-Home Care Agency assist you with completing the Provider Information section in your claims package forms, and we’ll talk just a bit about LTCI companies’ ethics.

Call (760) 744-8200 Today For Assistance With
Filing Your LTCI Claim and Your In-Home Care Needs!

A Servant’s Heart Care Solutions has assisted many clients and their families file their LTCI insurance claims since 2003.  It would be a privilege for us to have the opportunity to help your family as well!

Tim Colling
Tim Colling

Tim Colling is the founder and President of A Servant's Heart In-Home Care, which provided in-home caregiving services in San Diego County, and also of A Servant's Heart Geriatric Care Management, which provided
professional geriatric care management services and long term care placement services in San Diego County. Tim has more than 30 years of experience in management in a variety of industries. He held a Certified Care Manager credential from the National Academy of Certified Care Managers. Tim is also a Certified Public Accountant (retired), and received his Bachelor’s Degree in Accounting from California State University at San Diego. In addition to writing blog posts here for the Servant’s Heart blog, Tim also is a regular contributor to and to as well as blogs of other eldercare services provider companies. Finally, Tim is also the president of A Servant's Heart Web Design and Marketing, which provides home care marketing as well as website design and online marketing for those who serve the elderly and their families.

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