Navigating LTC Insurance Claims with Bill Comfort

📋 Long-term care insurance can be a lifeline—or a landmine—if you don’t know how to navigate the claims process.

I sat down with my colleague and mentor, Bill Comfort, to talk about something we don’t discuss nearly enough: how to confidently navigate a long-term care insurance claim when the time comes.

From why claims are more complex than most people expect, to what families and professionals need to know before filing, this conversation is packed with insight, practical tips, and eye-opening stories that every advisor, caregiver, and policyholder should hear.

We also talk about the growing wave of claims coming in the next decade—and how the professionals around those families can make all the difference in helping them receive the care and support they deserve.

🎧 If you’ve ever wondered how to help a loved one (or client) get the most from their policy, this one is a must-listen.

For additional information about Kelly, check her out on Linkedin or www.SteadfastAgents.com.

To explore your options for long-term care insurance, click here.

Steadfast Care Planning podcast is made possible by AMADA Senior Care and Steadfast Insurance LLC.

Come back next time for more helpful guidance! 

Transcript

Kelly Augspurger [00:00:02]:
Hey everyone. Welcome to Steadfast Care Planning where we plan for care to live well. I'm Kelly Augspurger, long-term care insurance specialist and your guide. With me today is Bill Comfort long-term care insurance specialist, owner of Comfort Long-Term Care, founder of the Long-Term Care Claims Professional training program, and my colleague and mentor. Bill, thanks so much for being here today.

Bill Comfort [00:00:26]:
This is great. I'm glad we're getting to do this, Kelly.

Kelly Augspurger [00:00:28]:
Today we're going to be talking about long-term care insurance claims and how to best navigate them. So Bill, can we jump right in?

Bill Comfort [00:00:36]:
Sure.

Kelly Augspurger [00:00:36]:
Okay. Well, Bill, I know it's been said that a long-term care insurance claim tsunami is on the horizon. What inspired you to create the LTCCP program? And with that claims wave coming, what should professionals, or families, be doing to be ready?

Bill Comfort [00:00:54]:
Yeah, that's probably a great couple questions we could spend the whole time discussing. I actually created the Long-Term Care Claims Professional, or LTCCP program for short. I created it 10 years ago and it was an outgrowth of training that I was already doing on a private consulting basis with home care agencies across the country, teaching home care providers how long-term care insurance works from a claims perspective. And the training program was really an outgrowth of individual training that I had done with different agencies, different companies.

Kelly Augspurger [00:01:37]:
Okay.

Bill Comfort [00:01:37]:
And I had been mostly using the training program just with my private consulting clients, training home care agencies primarily. And last year I was asked to kind of expand and update the program by one of my home care clients. And it just started to strike me from my experience in kind of looking back at the claims issues, what were some of the big questions, some of the big problems, looking at what was happening with my own clients who I've had for close to 30 years, who themselves are going on claim, what needs to be added to the program. And it struck me that of the 7 to 8 million policies that are in force, long-term care insurance policies, close to half of them, maybe 3 and a half million, maybe a little more than that, were written in just a 10 year period between about 1995 and 2005, which were our peak sales years. And when people buy long-term care insurance, they buy it in their 50s and early 60s most commonly.

Kelly Augspurger [00:02:45]:
Right.

Bill Comfort [00:02:46]:
And claims aren't expected by the insurance company, or the policyholders for 20 to 30 years.

Kelly Augspurger [00:02:53]:
Yeah.

Bill Comfort [00:02:53]:
But here we are today and what's really interesting is just last month there was a very interesting study that was published by a group of long-term care insurance actuaries. And we'll put the graphic up. Hopefully this will kind of work and come through. This shows the volume of claims that we're expecting. So today we're paying just under $20 billion a year for about 400,000 people on claim. In 16 years, this wave, this claims wave or claims tsunami, is going to peak at like $46 billion or over 1 million people on claim. So for care providers, particularly home care agencies, assisted living, and memory care facilities, which is the kind of care that people buy with long-term care insurance.

Kelly Augspurger [00:03:48]:
Yeah.

Bill Comfort [00:03:49]:
Those professionals need to be equipped to help their clients with long-term care insurance navigate more effectively, more efficiently. This by its nature complex claims process for long-term care. And I think other advisors, geriatric care managers, and of course agents and financial planners who have clients, maybe they didn't even sell them the policy, but they want to help their clients navigate the process. So this is all coming together with my 15 plus years of training the home care industry and really expanding and updating this claims training program for those and other professionals. This claims wave is kind of proving the concept. And just last point on this little graphic here. Even though the peak of this wave hits in about 15, 16 years, the level of claims doesn't come back to today's level for 30 years. And this graph, this study, Kelly, does not even include new sales.

Bill Comfort [00:04:58]:
It's just projecting the policies that are already in force. So it's probably not going to taper off as dramatically as this has shown. So for the next 30 years, we're going to have more claims than we've ever had. And that's really the impetus for this training program and why consumers, families who own long-term care insurance on their older family members need to start learning what might happen and their advisors and then the professionals who serve them as caregivers really have a critical role to play in making that claims process work and work well, meaning efficiently without unnecessary delays and complications.

Kelly Augspurger [00:05:44]:
Thanks for that overview there, Bill. You said something that stood out to me and hopefully viewers caught this. It's a little scary, but you said this complex long-term care insurance claims process, what makes it...and we'll probably, I know we're going to be talking about this throughout today's episode...but what makes it complex, especially compared to other insurance claims processes? So we think about like life insurance, disability, even health insurance. Why is the LTC claims process complex, especially, when compared to those other types of insurance?

Bill Comfort [00:06:18]:
Yeah, and without being kind of morbid, or flippant about it, a life insurance claim is fairly easy. You're either living or you're not. I mean, and that's...but kind of putting a fine point on that helps us compare it to long-term care insurance. And it's complex by its nature because it has to deal with, with a range, a continuum, if you like, of care needs, impairments, or frailties, or limitations.

Bill Comfort [00:06:52]:
And we'll talk about what those sort of benefit eligibility triggers are. But there's a wide range of those. And as we say, you know, when we're doing the CLTC training that you're part of, as well, that long-term care needs itself and long-term care insurance starts long before you're flat on your back unable to do anything. So how do you measure that? When does it begin? The other complexity is the policies have to be able to pay for another continuum and that's care services, home care, adult daycare, assisted living, memory care, and yes, if it's ever needed, maybe care in a nursing home. And all of those things have to be defined and all of those things have to be reviewed, processed by the insurance company. And that's what makes it complex.

Kelly Augspurger [00:07:45]:
So because of this complexity, all the more reason that we need to be equipped to know, "How do we navigate this? How do we, from the very beginning, to the middle, to the end, what are the best things that we need to do in order to help our clients?" And then even for families and professionals, how can they best be equipped in order to navigate this process? So, Bill, what are some of the biggest mistakes that you see that are made when submitting a claim?

Bill Comfort [00:08:11]:
Yeah, I think the biggest problem...let me start with that first because I think this overrides and kind of colors mistakes that are made. The biggest problem is it's very technical. There's very technical definitions in the policies. Well, naturally, consumers, the policyholders, the family members of the person who needs care, they don't speak insurance.

Kelly Augspurger [00:08:41]:
Right.

Bill Comfort [00:08:42]:
It's just, I mean, they don't. And unfortunately, insurance companies don't speak consumer very well. And I hope that can improve. I hope the carriers can do a better job of communicating what is needed, what are the criteria, what has to happen. But they use the language of their policies and they kind of have to, legally. So sometimes it's just a matter of interpretation. So a mistake that's made, and this is kind of a general idea, is too many policyholders, or their families or representatives who are part of starting the claim, filing the claim, going through the process, they don't take enough time on their own, to understand what is in the policy and how does it work. And so of course, they're in crisis.

Bill Comfort [00:09:37]:
Somebody needs care. That's very emotional anyway. But you call the insurance company and they start throwing terms out, start throwing requirements out. If you don't have any foundation for that conversation, that's hard. Now, that's a big burden to put on a family that's in crisis. Which is why I think it's so important that financial advisors, and particularly the professional home care providers and geriatric care managers, for example, that they're well versed in the language of this insurance. Because those are all the different people who can help coach and guide and partner

Bill Comfort [00:10:16]:
with their clients, with the consumers who are having to navigate the process.

Kelly Augspurger [00:10:22]:
So what are some of the most important things to ask or do for these professionals even before they submit a claim and start filing that paperwork?

Bill Comfort [00:10:30]:
Yeah, whether...it's a great question...so whether it's the professional advisor, or caregiver, or the policyholder and her family, you have to have a copy of the actual policy.

Kelly Augspurger [00:10:45]:
Yeah.

Bill Comfort [00:10:45]:
Just a summary, just a schedule page, just a quote from 25 years ago, or a billing statement, that does not give you the information you need. You have to have a copy of that 40 or 60 page insurance contract because it has the definitions of what's the eligibility, what are the impairments, or the degree of disability that you have to meet for the policy to begin working. What's the definition of home care and a home care provider? Is home care even included in the policy? You know, 30 years ago, not all policies had home care in them. So you have to start with the contract itself. And I tell this and teach this to home care providers, as well. You need to sit down with your clients and look at the policy and understand what's there. And it's not just definitions. You know, does the home care agency that you want to work with, are they going to be covered by the policy? That's one question.

Kelly Augspurger [00:11:49]:
Yeah.

Bill Comfort [00:11:49]:
And the other one is how do different parts of the policy work? And we can drill into that a little further. So you have to have the contract. The good news is if you don't, if it's been lost, you call the insurance company and they have to send you a new copy. Now you got to plan ahead, right? Because sometimes they still use snail mail and it can take 4 to 6 weeks to get a copy of that policy. So I mean, for people that are maybe listening, if they have themselves or a family member. Do you have the policy? And if not, order a copy today. Get ahead of that game.

Kelly Augspurger [00:12:27]:
Right.

Kelly Augspurger [00:12:28]:
Okay. So we need the paperwork. That's really the first step. What does the policy say? What's the contract language? Because the contract is king. You might think you have X, but really you have Y. And so maybe you didn't remember exactly how the agent, or advisor described it, you forgot. Or maybe it was described to you incorrectly, or all the information wasn't given to you at the time. But it's also been maybe 20, 30 years.

Kelly Augspurger [00:12:52]:
So you forget. So you really need to have that contract. Your family, the professionals, need to have that contract in order to start going through it. Bill, what do you see as typical triggers? We use that word in our industry. What do you see as the typical things that are needed in order to file a claim and get approved?

Bill Comfort [00:13:11]:
Yeah. So first things first, nothing happens with long-term care insurance until you're benefit eligible. And that's as defined by the policy, or what we call what you just said, the benefit triggers. What is going to trigger, start the benefits from the policy. And in long-term care, we describe it as impairments, or degrees of impairment, type of impairment. I think you could think about it as kind of an old-age disability in a way. And the good news is there's a lot of uniformity with a few exceptions. And the uniformity is generally this and it's either/or, Kelly.

Bill Comfort [00:13:56]:
So either you need physical assistance, and that's measured through what people have heard as the ADLs or "activities of daily living", things like bathing, dressing, getting safely in and out of bed or a chair, those types of things. Or separately, you need supervision, somebody around because of a cognitive impairment, a mental limitation. And again, we think of things like Alzheimer's, or dementia. Could be a stroke or a head injury. You know, that's affecting the computer, not the machine.

Kelly Augspurger [00:14:31]:
That's it.

Bill Comfort [00:14:32]:
And it's either/or. So somebody maybe with early stage dementia, they can do all the physical activities, but they're not safe being left alone, which could be for a variety of reasons. So those two tracks either physical help with ADL's, or supervision for cognitive. And most common policies say that physical activity help, you need to have help with 2 out of a list of 6 activities that are prescribed in the policy. And even further, and this is back to this idea of long-term care starts a lot sooner than most people think or imagine. Help with an ADL.

Bill Comfort [00:15:19]:
In most policies it can be either hands on help. Somebody has to physically pick you up out of a chair. But it could be, for most policies, simply standby assistance. In other words, because of balance, or frailty, or fall risk, you are at physical risk doing these activities. So somebody needs to be there just in case within arm's reach, standby assistance, which is obviously a much lower bar. And so long-term care can start a lot sooner than people imagine. But this is why the claims today are mostly on policies written 20, if not 30 years ago.

Bill Comfort [00:16:00]:
And some of those policies back then maybe said has to be hands on only, that wasn't as common. But that's why you have to have the contract. And if the contract says it could be standby assistance, claims can often start a lot earlier than people think. Or again, just supervision for a cognitive limitation.

Kelly Augspurger [00:16:21]:
Right.

Kelly Augspurger [00:16:21]:
So physical or cognitive, not both, that's key here typically.

Bill Comfort [00:16:25]:
Right.

Kelly Augspurger [00:16:26]:
And potentially standby, or hands on assistance, those are really the key. So make sure you have the policy, read the contract. What does it say? If you have questions, contact the advisor, contact the insurance company, get clarification if you need it. So you know exactly what to expect at claim time, what needs to happen in order to get a claim approved.

Bill Comfort [00:16:45]:
Right, and by the way, if you as the policyholder, or you're advocating maybe for a spouse or a parent, and you're seeing these terms and definitions, which would be good standby assistance with an ADL, you have to communicate that level of need to your care providers and the insurance company needs to use that language. What's one of the biggest mistakes that I see from home care provider notes, care notes, and plans of care that home care agencies write? They only focus on when they're doing hands on assistance. If somebody has long-term care insurance, they need to be charting and recording and recognizing that there are safety risks if somebody is not there standing by. And that's outside of normal medical practice. If you think about it. Doctors and nurses and physical therapists and occupational therapists, they're kind of hands-on people.

Kelly Augspurger [00:17:46]:
Yeah.

Bill Comfort [00:17:46]:
They think of their care, their rehab even as being hands-on help. So educating the providers to use the language that a policyholder needs to certify that they're eligible, that's job number one.

Kelly Augspurger [00:18:05]:
Okay. And that sounds like that could be a big red flag, Bill, as far as if you're not communicating the right type of assistance, so standby, or hands-on, that you could run into trouble at claim time.

Bill Comfort [00:18:17]:
Absolutely.

Kelly Augspurger [00:18:18]:
So that is something that professionals in the family need to communicate and that we have in records. We have records from the professionals, we have records in the doctor's notes, so that the insurance company can more easily and quickly approve that claim.

Bill Comfort [00:18:32]:
Right, right.

Kelly Augspurger [00:18:34]:
The Steadfast Care Planning podcast is sponsored by the Certification for Long-Term Care, CLTC, an in-depth training program that gives financial advisors the education and tools they need to discuss extended care planning with their clients. Look for the CLTC designation when choosing an advisor. If you're looking to become a CLTC, enroll in their masterclass and enter "Kelly" in the coupon code field for $200 off. What are some other kind of red flags, or warning signs that a claim may run into trouble? And how can those be addressed earlier rather than later?

Bill Comfort [00:19:08]:
Yeah, I think for consumers this claims process feels adversarial. The insurance company doesn't want to pay a claim. Well, the insurance company has a responsibility to pay a claim if it's a legitimate claim, but it needs to be understood insurance companies should not pay claims that are not legitimate, or eligible. Because that's actually protecting the other policyholders. Because that protects the money that's in the pool for those who are eligible.

Bill Comfort [00:19:41]:
So the key here, as you suggested, is using the right terms, using the right language, understanding what's there. And some of the red flags that I see are, as I mentioned, care providers who are not consistently charting the fact that when the caregivers in the home, maybe they're physically helping the person dress, helping them get shoes and socks on, I see like compression stockings for people often very hard. For those who are mobility and activity compromised, that's hard to do. But there's also balance and fall risk. So the caregiver's around for showers, or for transferring, but they're really not physically assisting, hands-on, but they're there on a standby basis. Again, I can't repeat it often enough that that has to be noted on a regular basis by the providers. Let me flip that around.

Bill Comfort [00:20:42]:
Clients, policyholders who are communicating their care needs to the insurance company, maybe over the phone, or for an in-person claim assessment that most companies do, that older, beginning to be impaired, or limited person needs to understand that they should be communicating their worst day, not their best day. It's human nature to see ourselves as capable. In fact, we're wired to do that. It's not just denial, or pride.

Kelly Augspurger [00:21:18]:
Right.

Bill Comfort [00:21:18]:
We're really psychologically to be healthy, we have to continue to see ourselves as capable. But when it comes to communicating our need for care to go on claim, we have to be able to communicate, "Yes, I'm worried. I'm afraid of falling. I've had a couple falls. Thankfully, you know, it hasn't been bad. But what if I fall in the shower, or getting into the shower?" So communicating and coaching to use the right terms and expressions. They have to be fair.

Bill Comfort [00:21:51]:
You can't lie about what you need, or not need. But this idea of standby assistance, so many people don't understand it. And I've had clients who've said to an insurance company through an assessment, "Oh, yeah, I can do all those activities." And their daughter's sitting there going, "Mom, you can't put your shoes and socks on."

Kelly Augspurger [00:22:11]:
Oh, geez.

Bill Comfort [00:22:12]:
"Well, I know, but I wear slippers." "Well, you can't wear slippers out of the house. And they're actually not safe to wear around the house. You're not able to fully complete dressing."

Kelly Augspurger [00:22:23]:
Right.

Bill Comfort [00:22:23]:
You know, so again, this is back to benefit eligibility. Once somebody's benefit eligible, everything then begins to work. I think the only other big red flag is when, particularly for home care, the definitions around home care don't meet up with the type of home care provider that maybe the client wants to use.

Kelly Augspurger [00:22:49]:
Bill, can you give us an example of that? So if there's a home care definition and they want a different type of home care, what does that look like?

Bill Comfort [00:22:56]:
Yeah. Well, and again, first of all, the policy has to cover home care to begin with.

Kelly Augspurger [00:23:00]:
Sure.

Bill Comfort [00:23:00]:
If it's nursing home only, or facility only, it's not going to cover home care.

Kelly Augspurger [00:23:04]:
Right.

Bill Comfort [00:23:05]:
You didn't pay for home care. It doesn't matter that home care might be less expensive in a certain situation. You bought a certain kind of policy.

Kelly Augspurger [00:23:14]:
Right.

Bill Comfort [00:23:15]:
So if home care is covered, then the definition of who's the provider, and the most common definition is if there's an organized professional agency. And most policies will say things like that the agency has to be licensed by the state if licensure is required. So for things like bathing and dressing and transferring what we call custodial care, personal care, there are many states that don't license those agencies. So if not licensed, you then want to look at the policy and make sure that the agency meets all the criteria. And most of them do. Where we see issues is where somebody wants to hire, say, just a private individual, maybe a neighbor, maybe it's somebody from town who is a single person who's got a great list of references, but they're just on their own. They're a independent contractor, caregiver.

Bill Comfort [00:24:14]:
Most policies will not cover that kind of person.

Kelly Augspurger [00:24:18]:
Right.

Bill Comfort [00:24:18]:
I'm working on a claim right now where this man's needs have increased over the last year and a half. And he's had private caregivers hired and managed by a geriatric care manager that he pays for. And now he's going on claim because his care needs have advanced, that he's eligible, but he's going to have to shift to using an agency to provide caregivers because independent caregivers aren't covered by his policy. Some do, but it's really more of an exception, particularly when we look back again, 20 to 30 years.

Kelly Augspurger [00:24:54]:
Right.

Kelly Augspurger [00:24:54]:
So something that you said just a minute ago about the person that needs the care, they really need to vocalize their worst day and not their best day. I think that is huge and that is monumental in that claims process. This is not the time for people to be bold and brave and just say, "I'm great." Like, "Oh, yeah, I just need a little bit of help, just here and there now and again." No, you need to speak very truthfully with detail. What kinds of things do you actually need help with in order for you to age more safely? A lot of people want to stay in their home. So how can we best age successfully safely in our home? Well, you may need assistance. So what does that assistance look like that needs to be conveyed.

Bill Comfort [00:25:38]:
You're using a key word there, "safety". So what we need to do as advisors, what we need to be coaching clients in is describing their concerns about their safety. "I don't feel safe doing this. I don't feel safe doing that." "Well, can you do it?" "Yes, but I don't feel safe," or if there's been any kind of a fall, even if it's been minor, which, by the way, brings up another thing to try to do ahead of time. I often ask and coach professional advisors and care professionals to ask their clients, does your primary care physician know about these concerns, or these things that have happened at home, particularly if there have been falls, if there's been a couple of falls, but they haven't been severe, meaning the person hasn't gone to urgent care or hasn't gone to the emergency room. Their primary care physician is not going to have any record of that.

Kelly Augspurger [00:26:38]:
Right.

Bill Comfort [00:26:38]:
But that's a sign that there are issues there, that if care isn't provided, things could go very badly if there's another fall. So make an appointment with your primary care physician. For just a checkup, but then tell him or her what's happening at home. Ask them to put into their care notes that you've had a couple of minor falls and that there's safety concerns because the insurance companies put a lot of weight on doctor's records. Sometimes too much weight. "Well, the doctor doesn't say, you need this kind of help."

Kelly Augspurger [00:27:14]:
Yeah.

Bill Comfort [00:27:14]:
Because the doctor's not in your home.

Kelly Augspurger [00:27:16]:
Right, right.

Kelly Augspurger [00:27:17]:
And you're not telling them too.

Bill Comfort [00:27:19]:
Yeah, exactly, exactly. So I think that can be really...we talk about what could you do ahead of time, or what do you need to anticipate. Make sure especially your primary care doctor knows what's going on. Somebody's got a cognitive impairment, Alzheimer's or dementia, for example, their neurologist might really be their primary. But you know, sometimes a family member has to go along, that healthcare power of attorney, or just spouse or daughter to say, "Hey, Dr. Jones, we really need you to make a note in the records that some of these things are happening at home."

Kelly Augspurger [00:27:55]:
Right. And I think that's where the family can play a great role is going to these doctor's appointments, PCP specialists. If mom or dad is not speaking up and telling the doctor these things, then the adult child can speak up and say, "Well, wait a minute, mom, I think we're being maybe a little bit too...holding back a little bit. Let's tell the doctor what's really going on and what kind of assistance is needed." And so, if the adult child is available and can go, I think that's probably a great benefit to that person that is starting to need care, or starting to need assistance, slowing down, losing some mobility, that sort of thing, whether it's physical assistance or, the cognitive, that's certainly just as important, as well.

Bill Comfort [00:28:35]:
To have them go along and reminding that person who has these developing impairments, reminding them, "Hey, mom, remember what you told me about getting your shoes and socks on? You're just wearing pajamas all day because you're worried about falling?"

Kelly Augspurger [00:28:56]:
Yeah.

Bill Comfort [00:28:56]:
"Remember we had that conver..." "Oh, yeah, well, I do feel that way." That needs to be recorded, that needs to be expressed on the phone, or in the in-person assessment with the insurance company. And the more elements that you have of the same message, the more efficient the claims process will be.

Kelly Augspurger [00:29:16]:
Right.

Bill Comfort [00:29:17]:
If you only tell it to the insurance company over the phone and they can't back it up with some other records, they're going to be a little more skeptical. I mean, again, we could be cynical about it and say they don't want to pay a claim, but it's really their job to be skeptical. So I think from a family standpoint, help build the story and get the information in multiple places. Physicians, if you're already getting care, make sure your home care agency is documenting things well. Sometimes family members have written a letter, "I'm, so and so daughter of this person. And here's what I see happening at home now."

Kelly Augspurger [00:29:58]:
That written proof is so critical. Yeah, yeah.

Bill Comfort [00:30:01]:
And that letter alone is not going to get somebody on claim, but it reinforces hopefully what else is in the records that the companies will look at.

Kelly Augspurger [00:30:09]:
Absolutely. The insurance companies need documentation. Without documentation, they cannot approve a claim. So we need it to be very black and white and not gray. Insurance companies don't like gray areas, right, Bill? They want it very crystal clear. Black and white.

Kelly Augspurger [00:30:24]:
Yes. These are the impairments. This is the assistance that's needed. This is expected to be an ongoing chronic condition. More than 90 days. So all of these things are very important in getting that claim approved. Bill, let's talk about timing.

Kelly Augspurger [00:30:38]:
How important is timing when it comes to starting a claim? Can waiting too long hurt the outcome of the person receiving care or getting a claim approved? Let's talk about the elimination period. What do you think?

Bill Comfort [00:30:51]:
Well, okay, so there's a lot of facets to that question. So let me start with this. The main questions I get from home care providers, and by the way, something like 80% of all long-term care insurance claims start at home. And that makes total sense. People want to stay home, if possible, as long as possible. For many people, that's why they bought long-term care insurance.

Kelly Augspurger [00:31:14]:
Yeah.

Bill Comfort [00:31:15]:
Was to be able to stay out of a nursing home, or facility.

Kelly Augspurger [00:31:19]:
For sure.

Bill Comfort [00:31:20]:
So what I tell clients, home care agencies, and so on. Excuse me, the question that I get is, "How do we help clients who say, 'I'm not yet ready to file a claim, I want to save my insurance benefits, benefits for later because I'm worried about care going a long time or we're only going to get a little bit of care now, which is less expensive. So I want to save my insurance dollars to when things get more expensive,'" obviously, particularly if they have a policy that maybe only pays for 3 or 4 years, for example.

Kelly Augspurger [00:31:54]:
Right.

Bill Comfort [00:31:55]:
And home care agencies are getting that sort of objection or pushback all the time. "Yeah, we have long-term care insurance, but we're not going to file a claim yet." So there's few things that pull all the facets of your question together with this. Number one, it doesn't make financial sense. I mean, $3,000 a month, which is probably 20 hours a week of home care today, maybe somebody could afford that from their own financial resources. But if you receive $3,000 from the insurance company, you get to save your $3,000 and use your own money later. I mean, at the end of the day, it's the same money.

Kelly Augspurger [00:32:34]:
Mm-hm.

Bill Comfort [00:32:34]:
The other thing people need to understand is if you only have a 3 year policy, but you wait a year and a half to file a claim because you want to save it, and then you go on claim and you die after a year, you lost most of the benefit of that insurance that you have.

Kelly Augspurger [00:32:53]:
That's a big gamble.

Bill Comfort [00:32:54]:
Yeah, it is. So that's kind of a psychological money management, financial planning question, Kelly. Financial planners can have a big role to play here in helping their clients recognize that not every time, but the general rule of thumb should be use the insurance money first. So the second piece of this is why not file a claim now and make sure you're benefit eligible? I mean, it's going to take 4 to 6 weeks to schedule the assessment, to write for doctor's records and get the doctors to respond, and send those records into the insurance company. The company has to review all that. Let's get through that process. Let's get that established.

Bill Comfort [00:33:40]:
You mentioned the elimination period, which is for long-term care insurance, it's the deductible. And most people are going to have something like 90 days. 60, 90, maybe 100 days. It could be shorter, could be a little longer. But 90 days is probably the most common. Most policies, not all this is something to look at in the contract, but most policies, once you get through that 90 days, it's one time. You never have to do it again. So why don't you start a claim, get your benefit eligibility determined, make sure your home care provider is a covered provider by the company, and get through your deductible period.

Bill Comfort [00:34:22]:
Cross that off. Now if you still want to pause, which again, I don't think is the best decision financially. If you still want to pause, pause it after the elimination period. And here's the last little thing that most people don't understand, or remember. Most policies, once you start receiving money. So after that elimination period, the companies waive, or forgive the premium.

Kelly Augspurger [00:34:48]:
Right.

Bill Comfort [00:34:49]:
And in some cases, if you have a couple, if one spouse goes on claim, they waive the premium for both.

Kelly Augspurger [00:34:56]:
Yeah.

Bill Comfort [00:34:56]:
So why not start the claim, stop paying premiums. And what I found is when people do this, they see through the 90 days the home care is so valuable, so helpful, benefits all the other family members, as well, that when they get to day 91, they continue to use it because they see the value in having that extra insurance money right now.

Kelly Augspurger [00:35:20]:
That's it. It is so valuable. So if you have it, in my opinion, you've been paying into this policy for probably many years. Right? Get as much as you can out of that policy because you've probably spent thousands of dollars over the years. Yes, right, tens of thousands of dollars. So get the benefits, collect the money when you can. Because like you said, we don't know how long a claim will last.

Kelly Augspurger [00:35:45]:
We don't know how long you will live after care starts. So you might as well get as much as you can out of the insurance company. Right? Yeah. Okay. Great stuff, Bill. The Steadfast Care Planning podcast is sponsored by AMADA Senior Care. AMADA provides complimentary consultation with a senior care advisor to find the right care from in-home caregiving to community care, as well as long-term care insurance claim advocacy and unique support partnerships for financial advisors to address family transitions and generational retention. To learn more, visit: www.SteadfastWithAmada.com.

Kelly Augspurger [00:36:25]:
Let's transition to the claims process and how it's evolved. So, over the last 10, 15 years, has it changed and what changes do you expect in the future?

Bill Comfort [00:36:36]:
Yeah, that's an interesting question. You're asking me to sort of get my crystal ball out a little bit, as well, which is pretty cloudy in my mind. The one I have, pretty cloudy. But I'll tell you, I think, I mean, I've sold long-term care insurance for 30 years. And so I've had a lot of clients go on claim and have worked with a lot of people over all of those years. I would say that today versus maybe 15 years ago. I think the claims process has become stricter. I think the carriers are looking at the details of claims in a much deeper fashion, if you like, in a more critical, or a more, from a consumer standpoint, a more negative fashion.

Bill Comfort [00:37:19]:
Part of that is driven by the fact that there's so many more claims coming. Insurance companies have to really know that it's a legitimate claim, which just means it feels more burdensome to consumers and people who have policies and their families. I think that's the significant change, but not unexpected and I would even say not even necessarily an unfair change.

Kelly Augspurger [00:37:47]:
Okay.

Bill Comfort [00:37:47]:
I think another trend is a lot of smaller companies who have stopped writing new business, so they have a fixed book of business that's getting older. A lot of those companies have handed off the claims processing to third party administrators. And this is good news, bad news. I've had some companies I've worked with that just the claims process was really difficult to work with them. And same company, now that this third party administrator has started working with them, the systems are better, it's more streamlined, it's more efficient, it's more claims focused in a positive way. So I'm seeing some advantage to that. The disadvantage is some of these administrators are administering claims for a dozen different companies, each of which might have a dozen or more different policy forms types that they wrote over the years. So these claims administrators might be having to manage a thousand different policy forms.

Bill Comfort [00:39:01]:
Sometimes the same policy in two different states has different language. And so that's another reason you have to know what your own policy says.

Kelly Augspurger [00:39:11]:
Yeah.

Bill Comfort [00:39:11]:
I'll give you a real quick example. I was working with a client of mine who had met the elimination period, but ended up being in and out of the hospital and wasn't consistently in his assisted living bed. So they hadn't actually paid a claim, yet, hadn't issued a check, yet.

Kelly Augspurger [00:39:30]:
Okay.

Bill Comfort [00:39:31]:
And the policy said, "The waiver of premium starts after you satisfy the elimination period period." And the spouse was frustrated because she had another premium coming due and it was a big premium. And I called with the client and the claims person said, "Well, we don't waive the premium until we issue the first benefit payment." I said, "That's not what the policy says." He said, "Well, that's our procedure." I said, "You don't get to do that. This contract says you waive the premium after the elimination period, which should have been three months ago, by the way." And we got that done, but it would have dragged out another month, or two if we hadn't had the policy to read and had pushed back a little bit.

Bill Comfort [00:40:14]:
So I think that's a trend in claims. Again, it's not necessarily a bad thing, but it reinforces why we really need to know what's in the policies and how they work for each individual.

Kelly Augspurger [00:40:27]:
Right.

Kelly Augspurger [00:40:28]:
And they are likely going to be different from each person because they've bought different years, different carriers, different policy forms. And so again, yeah, contract is king. What does the policy say? If the insurance company, just like you said, if they're going by procedure and not by what the policy says, that's when you need to challenge, that's when you need to push back and say, "Well, this is what the policy says. You need to follow the contract. It's a legal agreement."

Kelly Augspurger [00:40:54]:
Right.

Kelly Augspurger [00:40:55]:
It is contractual. So they are obligated to meet those terms.

Bill Comfort [00:40:59]:
And it goes both ways, Kelly. If somebody's not yet benefit eligible, if they truly only need help with one activity of daily living, they're not going to go on claim. And I've had to communicate that to some of my clients, as well. And they're like, "Well, okay," but we've prepped them and coached them to look for what's coming next, what are the safety issues, what does standby assistance mean? And that's fine. So that'll come down the road if it's needed.

Kelly Augspurger [00:41:28]:
Bill, what do you think about the future? Get that crystal ball out. What do you think claims are going to look like over the next 10 to 15 years? Do you think we're going to see more tech? AI? And how would that be integrated? What do you think?

Bill Comfort [00:41:42]:
So I think the insurance companies are going to use more AI to sort of read and interpret and digest and summarize things like doctor's notes. Where AI can look for key phrases around particularly benefit eligibility. And I think that is generally a good thing and can make it more efficient. Look, companies have to get more efficient. Yeah, we're going from 400,000 claims today to close to a million one in just 16 years. That's a huge ramp up. So the carriers have to get efficient that way.

Bill Comfort [00:42:16]:
We are seeing more and more companies delivering information. I had a client just last week who had requested a copy of the policy, and I said, "You might have to wait 4 weeks to get it through the mail." They emailed a PDF! No kidding? Wow! To the client. And I mean, that was a great surprise. So that's technology that helps. Submitting notes, submitting documents, through a scan and a portal upload. Carriers don't really want to receive things through email because this is all HIPAA protected medical information, basically. So carriers, they want to make sure they're protecting information for their responsibility, but also want to make sure people aren't exposing themselves.

Bill Comfort [00:43:07]:
And so the technology to do that is great. But one company, one big company just announced last year that they're no longer going to accept any information, or documents via fax. You either have to mail it, or upload it through a portal. Well, I got to tell you, I have a lot of clients in their late 70s, 80s, and maybe it's a husband and wife, one of them is independent. But Kelly, they're just not good at that stuff. They don't have a scanner.

Kelly Augspurger [00:43:36]:
Right.

Bill Comfort [00:43:36]:
My mom has a scanner. She's in her mid-80s, but she doesn't know how to use it. She can make a copy, but she can get there. But for you and me, it's natural. So I think one of the things we have to be careful of from the insurance company side is to not have technology get ahead of what our customers, our policyholders, particularly those going on claim, or older. Is it technology that they can navigate or have we complicated the process for them? And that's one of my concerns. My biggest future view is, and this is partly my passion for the training, is we have to get better, we have to get more efficient, we have to get more consumer friendly. And I'm talking from the insurance company side, because if we don't, if we make it confrontational, if we make it difficult, if we make it too complex, and sometimes it's perception, unfortunately, when we go from 400,000 people to a million people navigating this process, if people don't have a good experience at the time of claim, that's going to reflect poorly on the public and the value of even buying this insurance to begin with.

Bill Comfort [00:44:58]:
So I think managing claims well, the insurance industry has an opportunity to enhance our ability to sell and for consumers to buy this insurance. But the flip side's also possible. If we don't do it well, we're going to be facing a huge PR problem. And by the way, that's already out there. People already perceive it's too complex. Companies don't want to pay. They throw up all these hurdles. Most of those times, those complaints are because people don't understand the contract.

Kelly Augspurger [00:45:31]:
We don't need more of it, though, right? We don't need more bad PR because there's already enough of it. We need the good stories. Insurance companies are paying claims. These policies are saving and protecting families. But it comes down to what does the policy say? Are you benefit eligible? If you are, okay, they're going to pay claims, right?

Bill Comfort [00:45:50]:
Right.

Kelly Augspurger [00:45:51]:
Yeah, they will pay claims. They have to pay claims. Contractually. Gosh, we have talked about a lot today. Just a couple more things that I'd love to just briefly touch on with your LTCCP training program equipping professionals to confidently guide families through that process. How do you do that? And how can home care agencies, financial professionals, how can they take this course? Where do people go to do that?

Bill Comfort [00:46:14]:
Yeah, so everything, like so much today, starts online. So LTCCP.com which is Long-Term Care Claims Professional, LTCCP.com there's information about the curriculum. We teach via live Zoom classes which is a 5 to 6 hour live session, one time session, students can self-study. We're building video modules of the live training so people can even have that experience if they want to self-study for the course. There's 150 page textbook that also becomes kind of a resource reference. There you go.

Kelly Augspurger [00:46:56]:
I'm holding up the textbook.

Bill Comfort [00:46:58]:
For those who've taken the class and there is an exam, there's a comprehensive final exam and it's really, it's not built for consumers, it's built for care professionals. Like I've said, geriatric care managers, I think insurance and financial professionals who want the knowledge, want the ability to be involved at the time of claim. I think the training's invaluable for any of those professionals who are advising clients on the claims process. We have continuing education credits pre-approved for certified senior advisors, certified case managers, and care managers, certified CMC professionals. Those are geriatric care managers for example. So there's additional value in the course, as well, for many of these professionals.

Kelly Augspurger [00:47:50]:
And I gotta tell you, those people that are listening that if you are a financial professional, or you are a case manager, or care coordinator, or home care agency, this course really is so valuable and helpful. I took it myself as a long-term care insurance specialist. I have a young book of business, my clients are not on claim, yet. They are probably at least 10 years out from claim, most likely, hopefully. And so for me though, it's valuable information so that when the time comes I can offer that advice and I can let them know, "This is what to expect at claim time."

Kelly Augspurger [00:48:25]:
It is not an overnight process. It does take a little bit of time. But once that claim gets approved, your family is so grateful. They're just so overwhelmed because it really relieves a big burden on the family financially, but then physically, and emotionally. So I highly encourage you, if you are a financial pro, or are in the care industry to take this course. Get equipped, get that training so you know how to best navigate this claims process and educate the families that you're working with. All right, Bill, final advice: How people can plan for care to live well, what do you got?

Bill Comfort [00:48:58]:
Long-term care insurance. I mean you summarized it great. It works. Most claims are paid, 95% of claims are paid and those that aren't, are people who aren't eligible, yet, for the most part. Sometimes it's a slog to get there. But the better prepared you are ahead of time to start the claim, the smoother the process is going to go. But you know what? You have to plan ahead. You have to buy the long-term care insurance in your 50s, your early 60s, so that you're eligible to even qualify for it, to have it when you get older and need care.

Bill Comfort [00:49:33]:
So you got to plan ahead. And if you, or a family member, a loved one, is beginning to have safety issues and they have long-term care insurance, get ahold of that policy and figure out what's really in there. Call on somebody like Kelly, or other advisors who understand this insurance from the claims perspective to help you know what you have, as well.

Kelly Augspurger [00:49:54]:
That's it. We know that long-term care insurance is an effective and efficient way to pay for care. We also know if people don't even have long-term care insurance, if they miss the boat, that's too late. They didn't get it. You still need a written plan of care. You still need to have that conversation with your family. Who are the caregivers? Where do you want to receive care and can you receive care and how are you going to pay for it the most effectively. So identifying those things are really important. And also having your estate plan, making sure you've got your POAs, your will, your living will, trust if you need it, having all those things together are really helpful and going to be enormously valuable for your family.

Kelly Augspurger [00:50:31]:
So get going guys. Do the stuff, right? Make a plan, get after it because your family will thank you. So Bill, thank you so much for your time and expertise today. Always a pleasure talking with you. Have a wonderful day.

Bill Comfort [00:50:43]:
Thank you. Kelly.