A private long-term care policy is a contract, and most families meet its terms for the first time when a claim form arrives. By then the waiting period has already started, the form wants a signature from someone who is not in the room, and the policy number is somewhere in a drawer. You can read the contract before any of that happens.
Local option: New Plan Care gives families in the St. Louis area in-home help so a parent can stay home: companionship, help with bathing and dressing, meals, and overnight care. Call (314) 405-0887.
Start with the policy pages, not the brochure
The brochure lists what the company hopes you will remember. The policy pages list what it will pay. Find the schedule of benefits, the definitions section, and the claim section. Check that premiums are current. A policy that has lapsed, or that is in a grace period, needs a call to the company before any claim is filed. Check whose name is on the policy, because the person who signs the claim is often the one the policy names.
The waiting period
Most long-term care policies have an elimination period, a stretch of days at the start of care before benefits begin. Find the number, then find out how the days are counted. Some policies count calendar days. Some count only days on which covered care was received. Some require that the care come from a licensed agency or be certified by a named professional. Write the counting method next to the number. The family may pay for many days before the policy starts to pay, and the counting method decides how many.
The daily limit and the total pool
Find the daily or weekly benefit amount and the total the policy can pay over its life. Then find out what the money is paid for. Some policies pay only licensed providers. Some offer a cash benefit that can be used for unpaid family care under stated conditions. Some pay the provider directly, and some reimburse the person who paid. The answer changes what the family should be keeping. Ask the company in writing which kind of policy yours is, and keep the reply.
What the claim asks someone to certify
Most claims require a licensed professional to state that help is needed with daily activities, or that a cognitive condition requires supervision. Check which professional the form names, whether a plan of care must be attached, and whether the signature has to come from a provider you have not yet used. Do not assume your loved one's current doctor will sign the claim. Ask the company who may certify, and ask the agency whether it can complete its section.
The packet that has to match
Before you need it, ask the company for the complete claim packet and read every line. List each form, each signature, each provider number, and each attachment. Ask the agency for the information it will need, such as its tax identification number and the name of the person who signs its section. Keep the list in the same folder as the policy. A claim can stall on one missing page, so the list matters.
Keep the paper and the names
Copy each page you send, and write down the date and the method you used to send it. When you call the company, ask for a claim number, and write down the name of the person you spoke with. These are small habits, and they are the only record you will have if the company later asks what happened.
What this policy does not decide
A private policy is a separate contract from the hospice benefit, which has its own rules. Do not read one as answering the other. Questions about how the policy fits with public programs, or what a clause means in law, belong with a licensed advisor or with the company in writing. This guide is for checking the paperwork, not for interpreting it for you. The Sources page lists the references behind this site, and How We Write explains how the guides are built.