Insurance - Long-Term Care - Gatekeepers
Some of the most important features of a long-term care insurance policy are the provisions relating to gatekeepers. Gatekeepers are the individuals who decide extremely important issues, such as whether a person is eligible to buy coverage and whether a policyholder's placement in long-term care is warranted.
Eligibility
When a person applies for a long-term care policy, he or she must complete and sign an application form, which includes certain questions relating to the condition of his or her health. At that point, some companies underwrite the application, which means that they evaluate your health status before they decide to issue the requested insurance. During the underwriting procedure, the company investigates the applicant's health status by reviewing not only the application but also the applicants' medical records.
It is critical that applicants answer all of the questions truthfully and to the best of their ability because insurance companies can later deny coverage if they relied on false answers that were material to their decisions to insure. In fact, it is wise for applicants to refer, on their applications, to their medical records for more complete answers, and to state that they do not recall when they do not remember dates or other relevant information requested on applications.
Other insurance companies do not underwrite applications when they are made. Instead, after a claim is made for long-term care, they investigate the truthfulness of the statements made in the application, also examining medical records at that time. This is called "post-claims underwriting." If a company determines that a policyholder made a material false statement on his or her application, the claim is denied. In some states, this practice is illegal.
Entitlement to Benefits
After a policy is issued and a decision is made that a person needs long-term care, someone must decide whether the long-term care insurance policy will cover the care. A few policies defer to an insured's physician. If that physician certifies that long-term care is needed and the other aspects of the policy are met, coverage is assumed. However, the policies issued by most companies require the long-term care to be medically necessary for sickness or injury. As a result, most companies conduct their own evaluations of whether this standard is met, sometimes overruling, so to speak, patient's own doctor. Other policies require that the person be unable to complete a certain number of daily activities on their own, such as bathing, walking, dressing, and eating.
Copyright 2013 LexisNexis, a division of Reed Elsevier Inc.
